2002 Health Care in Canada www.cihi.ca Canadian Institute

2002 Health Care in Canada www.cihi.ca Canadian Institute
2002
www.cihi.ca
Health Care in Canada
Canadian Institute
for Health Information
Institut canadien
d’information sur la santé
2002
www.cihi.ca
Health Care in Canada
Contents of this publication may be reproduced in whole
or in part provided the intended use is for non-commercial
purposes and full acknowledgement is given to the Canadian
Institute for Health Information. To order additional print copies,
please use the order form at the back of this report.
Canadian Institute for Health Information
377 Dalhousie Street
Suite 200
Ottawa, Ontario, Canada
K1N 9N8
Telephone: (613) 241-7860
Fax: (613) 241-8120
www.cihi.ca
ISBN 1-55392-018-X
© 2002 Canadian Institute for Health Information
Cette publication est aussi disponible en français sous le titre : Les soins de santé
au Canada 2002 ISBN 1-55392-019-8
About the Canadian Institute
for Health Information
Since 1994, the Canadian Institute for Health Information (CIHI), a panCanadian, independent, not-for-profit organization, has been working to
improve the health of the health system and the health of Canadians by
providing reliable and timely health information. The Institute’s mandate, as
established by Canada’s health ministers, is to develop and maintain a common
approach for health information in this country. To this end, CIHI provides
information to advance Canada’s health policies, improve the health of the
population, strengthen our health system, and assist leaders in the health sector
to make informed decisions.
As of March 2002, the following individuals are on CIHI’s Board of Directors:
• Mr. Michael Decter (Chair), Lawrence
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Decter Investment Counsel Inc.
Mr. Tom Closson (Vice-Chair),
President and Chief Executive Officer,
University Health Network
Mr. Richard Alvarez (Ex-officio),
President and Chief Executive
Officer, CIHI
Mr. Daniel Burns, Deputy Minister,
Ontario Ministry of Health and LongTerm Care
Dr. Penny Ballem, Deputy Minister of
Health Services, Province of
British Columbia
Dr. Ivan Fellegi, Chief Statistician of
Canada, Statistics Canada
Mr. Rory Francis, Deputy Minister,
Prince Edward Island Ministry of Health
and Social Services
Mr. Ian Green, Deputy Minister of
Health, Health Canada
• Dr. Michael Guerriere, Chairman and
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Chief Executive Officer, HealthLink
Clinical Data Network Inc.
Mr. Terry Kaufman, Directeur général,
CLSC Notre-Dame de Grâce/Montreal
Ouest
Dr. Cameron Mustard, Scientific
Director, Institute for Work & Health
Dr. Brian Postl, Chief Executive Officer,
Winnipeg Regional Health Authority
Mr. Rick Roger, Chief Executive Officer,
Vancouver Island Health Authority
Dr. Thomas F. Ward, Deputy Minister,
Nova Scotia Department of Health
Ms. Sheila Weatherill, President and
Chief Executive Officer, Capital Health
Authority, Edmonton
Ms. Kathleen Weil, Chair of the Board
of Directors, Régie régionale de la santé et
des services sociaux de Montréal-Centre
About Statistics Canada
Statistics Canada is authorized under the Statistics Act to collect, compile,
analyze, abstract, and publish statistics related to the health and well-being of
Canadians. The Health Statistics Division’s primary objective is to provide statistical
information and analyses about the health of the population, determinants of
health, and the scope and utilization of Canada’s health care sector.
ACKNOWLEDGMENTS
Acknowledgments
The Canadian Institute for Health Information (CIHI) would like to acknowledge
and thank the many individuals and organizations that have contributed to the
development of the report.
Particularly we would like to express our appreciation to the members of the
Expert Group who provided invaluable advice throughout the development of the
report. Members of 2002 included:
• Mr. Steven Lewis (Chair), President,
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Access Consulting Ltd., Saskatoon;
Centre for Health and Policy Studies,
University of Calgary
Dr. John Millar (Co-Vice Chair), VicePresident, Research and Population
Health, CIHI
Dr. Michael Wolfson (Co-Vice Chair),
Assistant Chief Statistician, Analysis &
Development, Statistics Canada
Dr. Ross Baker, Associate Professor,
University of Toronto
Dr. Morris Barer, Scientific Director,
Institute of Health Services and Policy
Research, Canadian Institutes of Health
Research, University of British Columbia
Dr. Charlyn Black, Director, Centre for
Health Serivce and Policy Research,
University of British Columbia
Mr. Gary Catlin, Director, Health
Statistics Division, Statistics Canada
Ms. Carmen Connolly, Director,
Canadian Population Health
Initiative, CIHI
Dr. Victor Dirnfeld, Past President,
Canadian Medical Association; President
Medical Staff, The Richmond Hospital
Dr. Clyde Hertzman, Director,
Population Health Program, Canadian
Institute for Advanced Research;
Professor, Department of Health Care
and Epidemiology, University of British
Columbia
Dr. Alejandro Jadad, Director,
Program in eHealth Innovation;
Professor, Departments of Anesthesia
and Health Policy, Management and
Evaluation, University Health Network
and University of Toronto
• Mr. Jonathan Lomas, Executive
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Director, Canadian Health Services
Research Foundation
Dr. Frank Markel, Executive Director,
Joint Policy & Planning Committee
Dr. Richard Massé, Directeur national
de santé publique et Sous-ministre
adjoint Ministère de la Santé et des
Services sociaux
Dr. Cameron Mustard, Scientific
Director, Institute for Work & Health;
Public Health Sciences, University of
Toronto
Ms. Wendy Nicklin, Civic Campus
Operating Officer & Vice President
Nursing, Vice President Critical Care,
Emergency, Trauma, Obstetrics &
Gynecology, and Newborn Care, The
Ottawa Hospital
Dr. Denis Roy, Adjoint au directeur,
Direction de la santé publique, Régie
régionale de la santé et des services
sociaux de Montréal-Centre
Dr. Judith Shamian, Executive Director,
Nursing Policy, Health Canada
Dr. Robert Williams, Medical Director,
North Network, Timmins and District
Hospital
Ms. Jennifer Zelmer (ex-officio),
Director, Health Reports & Analysis, CIHI
HEALTH CARE IN CANADA 2002
It should be noted that the analyses
and conclusions in the report do not
necessarily reflect those of the individual
members of the Expert Group or their
affiliated organizations.
The editorial committee for the 2002
report included Steven Lewis, Jennifer
Zelmer, and Kira Leeb. Core members of
the project team also included Matthew
Alexander, Dalila Bakhti, Lisa Brazeau,
Janet Brown, Judy Brown, Paulina Carrion,
Zeerak Chaudhary, Ruth Diaz, Shelley
Drennan, Kristina Dubois, Lynne Duncan,
Patricia Finlay, Glenda Gagnon, Lise
Gagnon, Cheryl Gula, Sharon Gushue,
Erin Kennedy, Anne Lauzon, Anick Losier,
vi
Laura MacLeod, Haider Mannan,
David Marshall, Christina Mathers,
Karen McCarthy, Christa Morley, Lise
Poirier, Joan Porter, Marie Pratte, Indra
Pulcins, Maria Santos, Karin Schoeberle,
Serge Taillon, Linda Turner, Eugene Wen,
Juliann Yang and Scott Young.
This report could not have been
completed without the generous support
and assistance of many other individuals
and organizations. This includes
representatives from the many health
regions and the federal, provincial, and
territorial ministries of health who compiled
data, undertook research, and provided
financial and logistical support.
CHAPTER HIGHLIGHTS
Chapter Highlights
Care and Caring
What We Know
• Life expectancy at birth in Canada was 79 years in 1997, among the highest in
the world. But not everyone has the same chances for a long and healthy life.
Women have a higher life expectancy than men. There are also variations
among regions across Canada. Differences also exist in how Canadians rate
their own health. Overall, nearly two-thirds (61%) of Canadians aged 12 and
older said that their health was very good or excellent in 2000/2001.
• In 2000/2001, most Canadians (78% aged 12 and older) reported that they
had consulted a family doctor at least once in the last year. Many also sought
care from other health professionals. Consultations with dentists/orthodontists
(60%), eye specialists (38%), and other medical doctors (28%) were among the
most common.
• Canadians spent almost 21 million days as inpatients in acute care hospitals in
1999/2000, down 15.6% from 1994/1995. In contrast, more and more patients
underwent day surgery over this period. For example, the number treated grew
by 18% in Ontario.
• Hospitals in several provinces now track how long patients wait in the emergency
department after a health professional decides that they need to be admitted.
Data from Nova Scotia, New Brunswick, and Ontario show a median wait time
of approximately 1.5 hours in 2000/2001.
• About 4.9 million (or 19%) Canadians aged 12 and older reported seeing a
chiropractor or other type of complementary and alternative health practitioner
in 2000/2001, up from 14% in 1994/1995.
• At the same time, 13% of Canadians reported perceived unmet health care needs in
2000/2001, up from 6% in 1998/1999. Of these, half (50%) said that their reasons
for not getting care related to availability of care, including long wait times.
What We Don’t Know
• What is the impact of increased day surgery on the relative roles of the hospital,
homecare, and self care? How well is the changing mix of hospital services
meeting community needs?
• How does patient satisfaction with hospital care and other types of services compare
across the country? What factors explain higher and lower satisfaction levels?
• How do wait times compare across the country? What percentage of wait times
fall within recommended guidelines for different treatments? What is the
emotional and physical impact of waiting for different types of care?
HEALTH CARE IN CANADA 2002
The People, the Cost,
the Information
What We Know
• More than 1.5 million Canadians
worked in health care and social services
in 2000. The largest regulated health
professions are nursing (232,000 RNs
worked in nursing in 2000) and
medicine (57,800 physicians worked in
clinical and non-clinical practice in
2000). The numbers, geographic
distribution, workplaces, worklife, scopes
of practice, and other characteristics of
these and other health professionals
continue to evolve over time.
• Canada’s health care spending is higher
than ever before. It passed the $100
billion mark for the first time in 2001. In
total, we spent $102.5 billion (forecast)
to improve or maintain our health, an
average of about $3,300 per person.
Hospitals still account for the largest
share of spending (32% in 2001), but
spending on drugs—now accounting for
15%—displaced spending on physician
services (14% in 2001) as the second
largest cost driver in 1997.
• According to Statistics Canada’s Survey
of Household Spending, average health
care spending per household in Canada
in 2000 was $1,357, up from $1,009 in
1996. The largest share was for health
insurance premiums, followed by
medicinal and pharmaceutical products
and dental services. Health care
spending also differed by household
income. The highest income group spent
more than three times as much on health
care as the lowest income group,
adjusted for household size. But the lowincome group spent a larger share of its
after-tax income on health care in 2000
(3.9% versus 2.6%).
viii
• Today’s students are facing rising health
education costs. For example, the
average annual tuition fees for dentistry
programs rose from $5,425 to $8,491
(a 57% increase) between 1998/1999
and 2001/2002. Over the same period,
average tuition for medical students
increased 39% (to $6,654).
• Governments in all parts of the country
fund some homecare services, but what is
covered varies from place to place. In
1998/1999, Canadian governments
spent just under $3 billion on homecare,
up significantly over the last decade.
• The Internet has become a source of
health information for patients and
physicians alike. For example, a recent
survey by the Canadian Medical
Association reported that almost 80% of
doctors were using the Internet at their
home or office and 30% were referring
their patients to web sites on occasion.
What We Don’t Know
• Given demographic, workforce, health,
health care and other trends, how does
the current combination of healthcare
providers align with the health needs of
the current and future Canadian
population?
• What impact will changes in regulatory
models and professional scopes of
practice have on the supply and
distribution of health professionals, on
our ability to meet future healthcare
needs, on how professionals organize
and provide services, and on the quality
of care?
• How might different mixes of public and
private funding and service delivery,
particularly in rapidly expanding areas
such as drugs and home care, affect
costs, access, quality, and patient
outcomes and satisfaction?
CHAPTER HIGHLIGHTS
• How much is spent each year
specifically on health promotion and
prevention activities in Canada? How is
this changing?
• What are the effects on health and
health care of the increasing access by
individual Canadians and care providers
to vast amounts of health information
over the Internet?
Outcomes of Care
What We Know
• Overall, 19.2% and 12.6% of patients
died in a hospital within 30 days of
initial hospitalization for a stroke or a
heart attack, respectively between
1997/1998 and 1999/2000. After
adjusting for differences in age, sex, and
comorbidity, most of Canada’s largest
regions (populations over 100,000) had
mortality rates that were about the same
as this average, but some had higher or
lower rates.
• Across all regions (large and small),
7.3% of heart attack, 6.4% of asthma,
1% of hysterectomy, and 2.5% of
prostatectomy patients had an
unplanned return to hospital within 28
days due to a related health problem.
Most regions had rates that were similar
to the overall rates, but some were
significantly different, even after
adjusting for differences in risk factors.
• Five-year relative survival rates for
people diagnosed with some cancers
vary depending on where you live. For
example, five-year relative survival for
people diagnosed with prostate (91%) or
breast cancer (85%) was highest in British
Columbia. This compares to national
rates of 87% and 82% respectively.
• People receiving kidney or heart
transplants between 1995 and 2000
had better survival chances than those
who received transplants between 1989
and 1994.
• For many types of care and for many
different surgeries, research shows that
patients treated in hospitals with higher
numbers of cases are often less likely to
have complications or to die after surgery.
Most Canadians receive surgery in highvolume hospitals, but many hospitals
perform a very small number of
procedures. For example, almost one in
four pancreatic cancer surgeries—also
known as Whipple procedures—
performed in 1999/2000, were done in
hospitals that did fewer than five annually.
Some hospitals perform more than 25
procedures per year.
What We Don’t Know
• What explains regional differences in
mortality, readmissions, and survival rates?
• For which, if any, surgeries do hospitals
performing low numbers of operations
place patients at higher risk of
complications and death? For these
procedures, what is the optimal or
minimum number of cases a hospital
should perform to provide safe and
effective care? How many deaths could
potentially be prevented by ensuring
that surgery is provided at high-volume
centres? What would be the other
trade-offs if surgical procedures
were centralized?
• What is the relationship between how
much we spend on particular
interventions and the benefits they
provide?
• How healthy are patients three, six, and
12 months after most types of surgery?
ix
HEALTH CARE IN CANADA 2002
Public Health: On
Guard Year After Year
What We Know
• Smoking remains a public health
challenge for Canada. In 2000/2001,
5.5 million Canadians aged 12 or older
(almost 22%) said that they smoked
cigarettes daily, including 13% of 12 to
19 year olds and 10% of seniors. The
proportion of Canadians who reported
smoking daily has decreased over the
past two decades. In 1978/1979, 37% of
those 15 years and older reported
smoking daily.
• Canadian children are routinely
vaccinated against nine diseases: polio,
pertussis (whooping cough), tetanus,
diptheria, Haemophilus influenzae type b
(Hib), measles, mumps, rubella, and
hepatitis B. Provinces and territories each
develop their own routine schedules for
childhood vaccinations.
• In 2000/2001, Statistics Canada asked
Canadians if they had had a flu shot in
the last year. About two in three seniors
(65%) said yes, up from just over half
(51%) in 1996/1997. This compares to
27% of Canadians aged 12 and older,
up from just under 15% in 1996/1997.
• About a billion people living in
developing countries are at risk because
they are without clean drinking water,
according to United Nations estimates.
Most Canadians are more fortunate. We
generally have access to safe drinking
water, although outbreaks of water-borne
disease occur from time to time.
x
• The Canadian Task Force on Preventive
Health Care weighs the evidence on what
should and should not be included in
regular checkups for Canadians of
different ages. For example, they
recommend routine screening
mammograms for women aged 50 to 69
years and pap smears for women from
when they become sexually active or turn
18 (whichever is earlier) until age 69. In
2000/2001, 70% of Canadian women
aged 50 to 69 reported receiving a
mammogram for screening or other
purposes in the last two years. More (73%
of those 18 to 69) reported receiving a
Pap smear in the last three years.
What We Don’t Know
• How many Canadians are affected by
food- or water-borne illness each year?
What are the short and long-term health
consequences of their illness?
• How many children receive all
recommended immunizations on
schedule?
• Which among the wide variety of possible
health promotion strategies, many of
which aim to influence health outcomes
far into the future, offer the most health
gains relative to resources expended?
• How do voluntary, community, and
mutual aid groups, as well as the
corporate sector, contribute to health
promotion, disease prevention, and
health protection efforts?
CHAPTER HIGHLIGHTS
Medicating Illness:
Drug Use and Cost
in Canada
What We Know
• Millions of Canadians take medications
daily. Almost eight in ten Canadians
aged 12 and older (78%) said that they
had used one or more prescribed or
over-the-counter medications in the last
month in 1998/1999. Women and older
Canadians were more likely than others
to report using medications.
• Painkillers—ranging from aspirin to
morphine—are among the most
commonly used drugs. According to a
1998/1999 Statistics Canada survey,
about 65% of Canadians 12 and older
said they had taken painkillers in the
last month. Other commonly used
drugs include heart medications (13%),
stomach remedies (13%), penicillin or
other antibiotics (8%), sleeping pills
and tranquilizers (5%), and
antidepressants (4%).
• Retail drug sales became the second
largest category of total public and
private health spending (after hospitals)
in 1997, overtaking physician services. In
total, Canadians are expected to have
spent over $15.5 billion on drugs in
2001, up 8.6% from the previous year.
That is just over $500 per person.
• In 2000, manufacturers sold about $6.3
billion of patented medicines in Canada,
according to the Patented Medicine Price
Review Board (PMPRB). That’s just under
two-thirds (63%) of total drug sales across
the country, up from 43.3% in 1995.
Most of the remaining sales (28%) were
non-patented, brand-name drugs sold by
companies that also sell patented drugs.
“Generic” drugs—copies of drugs for
which the original patent(s) have
expired—accounted for about 9% of sales
in 2000.
• Three-quarters (75%) of Canadians aged
12 and older reported having some
public or private insurance coverage
(with varying levels of deductibles) for
prescription drugs in 1998/1999. Young
adults and low-income Canadians were
least likely to say that they were insured.
In part, this likely reflects the fact that
private insurance is often a benefit of
employment, covering employees and
their dependents.
What We Don’t Know
• How have changes in patent protection
and provincial/territorial drug programs
and formularies affected drug utilization,
costs, and patient outcomes?
• What strategies are most effective in
controlling costs and increases in
utilization, while ensuring high quality
patient care?
• Are the drivers of recent increases in
spending on drugs the same across
the country?
• What approaches help patients and their
caregivers to maximize the benefits of
medications while minimizing risks?
xi
Contents
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
About Statistics Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Chapter Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
About this Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: A Year in the Life of Canada’s Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . 5
New Reports with Some New Twists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Costs Are Up...But Consider the Long View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Health Human Resources: A Top Preoccupation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Searching for Better Ways to Organize Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Primary Care: The Elusive Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Science and Technology Forge Ahead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
More Changes to Come. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Part A: Inside Canada’s Health Care System .
Chapter 2: Care and Caring . . . . . . . . . . . . .
Medicare—and Other Care—Today. . . . . . . . . .
Choosing Other Options . . . . . . . . . . . . . . . .
What Canadians Think… . . . . . . . . . . . . . . . . .
…About Access to Care . . . . . . . . . . . . . . . .
Watching the Clock: Wait Times in Health Care .
A Sample of What’s Tracked . . . . . . . . . . . . .
Information Gaps—Some Examples. . . . . . . . . .
For More Information . . . . . . . . . . . . . . . . . . . .
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11
13
14
15
16
17
18
19
21
22
Chapter 3: The People, the Cost, the Information . . . . .
The People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Canada’s Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physician Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Care Providers of the Future . . . . . . . . . . . . . . . . . . . . .
The Cost of Studying . . . . . . . . . . . . . . . . . . . . . . . . .
Managing Health Care in Canada . . . . . . . . . . . . . . . . .
Spending on Health Care . . . . . . . . . . . . . . . . . . . . . . . . .
Dividing the Health Care Dollar: Who Pays? . . . . . . . . . .
How Canada Compares . . . . . . . . . . . . . . . . . . . . . . . .
A Closer Look at Canada . . . . . . . . . . . . . . . . . . . . . . .
Dividing the Health Care Dollar: Where the Money Goes .
Information: Another Resource for Health . . . . . . . . . . . . . .
Information Gaps—Some Examples. . . . . . . . . . . . . . . . . .
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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23
23
24
25
26
27
28
29
29
29
30
32
34
36
37
Part B: In-Depth Reports . . . . . . . . . . . . . . .
Chapter 4: Outcomes Of Care . . . . . . . . . . .
Surviving A Heart Attack or Stroke . . . . . . . . . .
New for 2002 . . . . . . . . . . . . . . . . . . . . . .
Returning to Hospital . . . . . . . . . . . . . . . . . . .
Readmissions for AMI and Asthma . . . . . . . .
Survival After a Cancer Diagnosis . . . . . . . . . .
When One Organ Fails… . . . . . . . . . . . . . . . .
After a Transplant…Survival . . . . . . . . . . . . .
On the International Front . . . . . . . . . . . . . .
Volume and Surgical Outcomes—Another Look
The Situation in Canada: New for This Year .
What the Data Show . . . . . . . . . . . . . . . . . .
Trade-Offs to be Made? . . . . . . . . . . . . . . .
Information Gaps—Some Examples . . . . . . . . .
For More Information . . . . . . . . . . . . . . . . . . .
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.39
.41
.41
.43
.45
.46
.48
.49
.51
.52
.52
.53
.54
.55
.56
.57
Chapter 5: Public Health: On Guard Year After Year . . . . . . . . .
Containing Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drinking Water Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ensuring Safe Drinking Water . . . . . . . . . . . . . . . . . . . . . . . . .
Boil-Water Advisories—An Immediate but Temporary Solution? . .
What Canadians Think . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A Shot in the Arm for Public Health . . . . . . . . . . . . . . . . . . . . . . . .
Protecting Canadian Children . . . . . . . . . . . . . . . . . . . . . . . . . .
Flu Shots for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Syphilis: The Promise and the Threat . . . . . . . . . . . . . . . . . . . . . . .
Women’s Health: Screening for Breast and Cervical Cancer . . . . . . .
Getting the Message Out: Snapshots of Health Promotion in Canada
Healthy Futures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When Will You Quit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reducing Harm: HIV Infection as an Example . . . . . . . . . . . . . . .
Coping with Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Who Responds? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Information Gaps: Some Examples . . . . . . . . . . . . . . . . . . . . . . . .
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.59
.60
.60
.61
.62
.63
.63
.64
.66
.67
.67
.69
.69
.70
.71
.72
.72
.73
.74
Chapter 6: Medicating Illness: Drug Use and Cost in Canada
The World of Pharmaceuticals: Regulating Drugs . . . . . . . . . . . . .
How New Drugs are Born, Developed, and Approved . . . . . . .
Watching for Problems after Approval . . . . . . . . . . . . . . . . . . .
Why Do Some Drugs Require a Prescription? . . . . . . . . . . . . . .
Who Takes What Medication? . . . . . . . . . . . . . . . . . . . . . . . . . .
Old or New? Choices to be Made When Prescribing . . . . . . . . . .
The Terms of Patent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How Much are We Spending? . . . . . . . . . . . . . . . . . . . . . . . . . .
Whose Drug Costs are Insured? . . . . . . . . . . . . . . . . . . . . . . .
Why is Drug Spending Rising? . . . . . . . . . . . . . . . . . . . . . . . .
Information Gaps—Some Examples . . . . . . . . . . . . . . . . . . . . . .
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.77
.77
.78
.79
.80
.80
.81
.82
.84
.85
.87
.89
.90
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Part C : A Look Ahead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Chapter 7: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
Index
Order Form
It’s Your Turn
ABOUT THIS REPORT
About this Report
Oct-01
Nov-01
Jul-01
Jan-01
May-01
Jul-00
Nov-00
Jul-99
Jul-98
Jul-97
Jul-96
Jul-95
Jul-94
Jul-93
Jul-92
Jul-91
Jul-90
% Respondents
Health and health care continue to be top priorities for Canadians. In the past
year, several provinces have completed strategic reviews of their health systems;
others have launched new studies. At the federal level, the Kirby Commission,
(undertaken by the Standing Senate Committee on Social Affairs, Science and
Technology and led by Senator Kirby) and the
Canadians’ Primary Concerns
1 Commission on the Future of Health Care in
What issues do you feel are the most important facing Canada?
Canada, led by Roy Romanow, both released
The graph below shows the top six national issues identified by
interim reports. Despite differences in
Canadians answering Ipsos-Reid polls over the last decade. In
emphasis and approach, a common theme
November 2000, health care was cited most often as the
greatest priority facing the country. Opinions have fluctuated
appears in all these studies and reports: that
recently, reflecting the events of September 11th, 2001.
we cannot improve what we cannot measure—
70%
and we cannot measure without timely and
60%
reliable data that provide an accurate picture
of the health of the population and how well
50%
the health care system is functioning.
40%
Health Care in Canada 2002, a joint
enterprise
of the Canadian Institute for Health
30%
Information (CIHI) and Statistics Canada, is
20%
the third in a series of annual reports
launched in 2000. It is part of an ongoing
10%
commitment to provide reliable data and
0%
analyses to inform the public debate. Each
report builds on those that have gone before,
Terrorism/National Security
Healthcare/Medicare
Economy
as well as on research gathered at the local,
Education
Unemployment/Jobs
Defence/Military
regional, provincial, territorial, national, and
Source: Ipsos-Reid.
international levels. Feedback provided by
health professionals, researchers, individual Canadians, the media, and others
also help identify new content areas.
HEALTH CARE IN CANADA 2002
Each year, we provide updated data and
expanded analyses on issues of enduring
relevance, as well as new information on
emerging topics. Who is using what types
of health services? What do Canadians
think about our health care system? How is
New for 2002
Every year the Health Care in Canada report
introduces new information on topics that are central
to understanding our health care system. Our choices
reflect both feedback received since the last report and
new data that have become available. This year, for
example, we focus on areas such as outcomes of care,
drug use and expenditure, and public health. The
importance of these topics partly reflects shifts in
approaches to health care and how we think about
health. Examples of the kinds of new information
contained in this year’s report are listed below. A
more complete list is available at www.cihi.ca.
• How patients’ chances of dying in hospital within 30
days of an initial admission with a heart attack or
stroke (adjusted for differences in several key risk
factors) vary region by region, across the country.
• How the amount that low-income Canadian
households spend directly on health care compares
to that spent by those in higher income brackets.
• How the chances vary, region by region, across the
country that patients who are hospitalized with a
heart attack, asthma, or for a hysterectomy or
prostatectomy have to return to the same or
another hospital for a related condition (adjusted
for differences in several key risk factors).
• How often different types of surgery are performed
at high, medium, and low volume centres and how
rates of surgery vary.
• How Canada’s largest health regions (covering more
than 90% of the total population) compare with
respect to key health and health care indicators.
• How total retail drug sales per capita and prices for
patented drugs in Canada compare with those in
other countries.
• How long patients in emergency departments wait
for a bed once it is determined that they require
admission to hospital.
• Self-reported rates of the use of different types of
health services and how they vary across the country.
• Who is most likely to receive mammograms and
pap smears and how rates vary across the country.
2
it changing? Are important aspects of
care—such as wait times and patient
outcomes—improving? Are costs increasing
or decreasing? These are but a few
examples of the questions addressed in
Health Care in Canada 2002.
We are fortunate to have better
information today than we had in the past
to support many decisions in health care.
But gaps remain. We hope, by highlighting
examples of what we know and don’t know
about many of the topics presented here,
we can continue to work with partners
across the country to narrow these gaps
over time.
The report is divided into three parts:
Part A: Inside Canada’s Health Care
System provides current information on
the continuum of care offered by our
health care system, on the professionals
involved in providing that care, and on the
associated costs and resources used.
Part B: In-Depth Reports focuses on
three areas in detail: outcomes of care for
specific diseases and procedures, public
health programs and results, and
medication use and expenditures.
Part C: A Look Ahead looks at the
on-going challenge of filling out our
understanding of how and how well the
health care system functions.
The report also includes an insert entitled
“Health Indicators 2002.” This convenient
reference features comparative data on a
range of health and health system
indicators for Canada’s largest health
regions (comprising more than 90% of the
total population) and for the provinces and
territories. Wherever the icon to the right
appears beside the text, it indicates that
related regional or provincial/territorial
data can be found in the insert.
i
ABOUT THIS REPORT
For More Information
Highlights and the full text of Heath Care
in Canada 2002 are available free of
charge on the CIHI Web site at:
www.cihi.ca. To order additional copies of
the report (a nominal charge applies to
cover printing, shipping, and handling
costs) please contact:
Canadian Institute for Health Information
Order Desk
377 Dalhousie Street, Suite 200
Ottawa, Ontario K1N 9N8
Tel: (613) 241-7860
Fax: (613) 241-8120
The companion document How healthy
are Canadians 2002? will also be available
through the Web, following its upcoming
release.
We welcome comments and suggestions
about this report and on how to make
future reports more useful and informative.
For your convenience a feedback sheet,
“It’s Your Turn”, is provided at the end of
this report. You can also email your
comments to [email protected]
There’s Also More on the Web!
The print version of this report is only part of what you can
find at our Web site (www.cihi.ca). As we did last year, on the day
that Health Care in Canada 2002 is released and in the weeks
and months following, we will be adding a wealth of information
to what is already available electronically. For example, it will be
possible to:
• Download free copies of the report and the insert in English
or French.
• Read highlights of the report in a plain language brochure.
• Sign-up to receive regular updates to the report via e-mail.
• View a presentation of the report’s highlights.
• Access some of the documents and data used in preparing
the report.
• Take an opportunity to look at previous annual reports
(including an on-line index to all reports) and other related
reports, such as Canada’s Health Care Providers and CIHI’s
regular series of reports on aspects of health spending, health
human resources, health services, and population health.
3
1. A YEAR IN THE LIFE OF CANADA’S HEALTH CARE SYSTEM
1. A Year in the Life of Canada’s
Health Care System
If a week is a long time in politics, a year is a very long time in health care.
The stream of new science and technology, front-page headlines of health care
magic and mayhem, analyses and reports, and new directions in public policy
flows on. This chapter offers a brief review of some of the events in the past year
in Canadian health care and sets the stage for the more detailed information
contained in the report.
New Reports with Some New Twists
Over the last two years, Quebec, Saskatchewan, Alberta, and other
jurisdictions tabled major reports about health care. Federal efforts—led by
Roy Romanow and Senator Michael Kirby—are still in progress.
The completed reports have yielded some things old, and some things new. The
strengths of the current system have a familiar ring. So do the critiques. For
example, many argue that:
Rethinking Health Care?
2 • information systems are obsolete and hinder
A series of Royal Commission and Task Force reports ushered
efficient, effective care;
in health care reform across Canada in the 1980s. As the new
•
primary care needs reorganization;
millennium begins, many governments have decided that it’s
time for another broad look at how health care is organized
• integration of services remains an
and delivered. Examples of recent and upcoming governmentunrealized ideal; and
initiated Commission and Council reports are listed below.
• rising costs are squeezing provinces’
They are complemented by thoughts from a wide variety of
academics, policy think tanks, health care associations and
capacities to invest in other important areas.
advocates, and individual Canadians.
Source: Compiled by CIHI
A major new thrust is an emphasis on the
importance of improving quality and reducing
errors. For example, the Fyke Commission
Report from Saskatchewan1 advocates
upgraded emergency response and a
regionalized system of hospital care
organized on a province-wide basis,
recognizing the difficulties in providing highquality acute care in most rural areas because
of insufficient personnel and technology and
low population densities. While the reports
acknowledge continuous innovation at the
clinical level, they also note that the system,
as a whole, can be difficult to change—old
cultures and attitudes persist.
HEALTH CARE IN CANADA 2002
And yet, these reports and their findings
come at a time of considerable change in
Canada’s health care system. We continue
to see important shifts in spending
patterns, human resources, how the system
is organized, primary care, science and
technology, and other areas.
Costs Are Up…
But Consider the
Long View
Health care spending rose in 2001,
as it has for the past four years. For the
first time ever, the total bill came to more
than $100 billion. Adjusted for inflation
and population growth, spending was up
4.3% from the year before. Public sector
spending grew by 5.7%. It now accounts
for about 73% of the total.
While the last four years saw spending
rise, the mid-1990s were a relatively lean
period in post-Medicare funding history.
The actual amount spent grew somewhat.
Health Care’s Share of the Economy
3
In 2001, Canada spent about 9.4% of our gross domestic
product (GDP), a measure of total economic output, on health
care. That’s up from the previous year’s 9.1% because health
care spending rose faster than overall economic growth. But it is
still below the peak of 9.9% in 1992.
12%
% of GDP spent on health care
10%
8%
6%
4%
2%
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000f
2001f
0%
Note: Open symbols are forecast figures.
Source: National Health Expenditure Database, CIHI
6
But when inflation and population growth
are taken into account, there was a dip.
The recent bust (roughly 1993-97) and
boom (roughly 1997-2001) periods
average out to about the long-term
historical growth rate.
Will recent growth rates continue in 2002?
Maybe, maybe not. The answer depends on
wage settlements, government budgets, how
much we each spend personally, and much
more. This year’s report profiles some of
these factors in Chapter 2: The People, The
Cost, The Information.
What happens may also depend on how
governments respond to recent health care
reports. Some of the reports suggested
fiscal diagnoses and cures—sometimes
firm, sometimes merely presented for
consideration—are similar; others reveal a
wide range of perspectives. For example,
Quebec’s Clair Commission2 advocates
private long-term care insurance. It
suggests that this could be a source of new
revenue to look after an aging population
in the future (birth rates in Quebec are
among the lowest in the world). Alberta’s
Mazankowski Report3 recommends
“diversifying the revenue stream,”
deinsuring certain medical services, and
considering medical savings accounts and
variable health insurance premiums. Early
reports from the Federal Senate Committee
on Social Affairs, Science and Technology
also open the door to exploring alternate
models. All three reports doubt that
internal reforms can adequately contain
costs and suggest exploring non-tax-based
sources to finance increases.
By contrast, the Fyke Commission Report
from Saskatchewan advocates far-ranging
internal reforms, rather than seeking
additional non-governmental revenue
sources or reducing the comprehensiveness
of publicly financed services. It is skeptical
that expanding the non-public component
of the system will either preserve equity or
control costs.
1. A YEAR IN THE LIFE OF CANADA’S HEALTH CARE SYSTEM
Health Human
Resources: A Top
Preoccupation
Health care is a people business. About
one in ten employed Canadians work in
health and social services. If the right
people aren’t in the right places to deliver
the right types of care, the system does not
run smoothly.
There’s a strong desire to understand
better who they are, what they do, how
many professionals we need, and how they
can work more effectively together. Not
surprisingly, health human resources
emerged as the number one issue from an
extensive consultation process with health
experts in 2001.4 And the media have
been full of stories about recruitment,
shortages, and contract negotiations.
Part of the challenge—and perhaps the
opportunity—is that the jobs that health
professionals do are changing. In some
cases, they are taking on new roles. For
example, Quebec recently changed its laws
to allow nurses to act as surgeons’
assistants. This means that they can
perform some surgical tasks, such as
stitching and closing wounds. In other
cases, the scope of professionals’ work is
shrinking. For instance, more and more
Ontario fee-for-service family doctors have
office-only practices.5 Fewer are working in
emergency rooms, doing house calls,
caring for patients while in hospital, and
delivering babies.
Research doesn’t tell us exactly what mix
of what number of health professionals
would work best for a particular
community. Different parts of the country
are using different strategies to find a
balance that works. Some—like recruiting
family doctors from other countries to
practice in under-served rural areas—can
have results in the short-term. (This strategy
may also have other unintended
consequences. In 2001, the South African
High Commissioner to Canada asked that
Canada stop recruiting their physicians
because they are needed at home.6) Other
strategies will take many years to show
direct results. Examples include recent
increases in enrollments in health science
education programs and trials of new
models of care.
Searching for Better
Ways to Organize
Health Care
Many provinces and territories
‘regionalized’ their health care systems
over the past decade. How these health
regions work, as well as what they do,
continues to evolve.
Regionalization of Health Care
4
In the late 1980s and 1990s, most provinces and territories
across Canada regionalized the delivery of health care. In some
provinces, further restructuring has recently taken place.
Source: Regionalization Research Centre, Health Services Utilization and Research Commission.
7
HEALTH CARE IN CANADA 2002
In general, governments have assigned
health regions responsibility for the dayto-day operation of healthcare services
for a defined geographic area. Goals
varied. But most jurisdictions aimed to
streamline services and to bring their
planning and delivery closer to local
residents.7 Other common aims included
increasing the focus on health promotion
and committing more resources to
community-based services.
The original objectives may have been
similar, but the size, responsibilities,
authorities, and structure of regions differ
from coast to coast and are changing. For
example, Saskatchewan recently collapsed
32 District Health Boards into 12 Regional
Health Authorities. British Columbia is
moving in the same direction. The 52
health authorities (11 Regional Health
Boards, 34 Community Health Councils,
and 7 Community Health Services
Societies), became 5 Regional Health
Authorities, 15 Health Service Delivery
Areas, and one Provincial Health Service
Authority in December 2001. Prince Edward
Island announced a similar model in April
2002. Its four Health Regions (down from
five) will be responsible for planning and
delivering primary health and social
services. A new Provincial Health Services
Authority will take charge of more
specialized services, including the
province’s two largest hospitals.
Governance structures are also changing
in some provinces. For instance, Quebec
and Saskatchewan recently switched to
appointed (not elected) boards of directors.
Alberta moved in the opposite direction. It
held elections for two-thirds of board
positions in October 2001. And New
Brunswick will hold its first board elections
in 2004.
8
Primary Care: The
Elusive Reform
Primary health care occurs where you first
contact the healthcare system—often in a
physician’s office, health clinic, or
community health centre. It can also be a
gateway to other types of care.
A desire to reform primary health care
has been a constant theme over the past
two decades. A common focus is to
establish multi-disciplinary, comprehensive
health centres that serve as the first point of
contact for the public and provide an
integrated and comprehensive range of
non-specialized services.
Variants of such centres have existed for
years, and there have been many
demonstration and pilot projects of
different models of care. But physiciancentred solo and small group private
practice remain the norm.8 No province
has universally implemented a
fundamentally new primary care model;
participation is generally voluntary.
There are signs that the pace of change
may accelerate in the near future. In
September 2000, Canada’s premiers and
the prime minister agreed that
improvements to primary health care are
crucial to the renewal of health services.9
More recently, Ontario has announced
plans to enroll 80% of the province’s
family doctors into teams or health
networks by 2004.
Other provinces have also made plans
for change. For example, Saskatchewan
has set a target of 25% of doctors
practicing in non-fee-for-service group
practices within 4 years and 100% within a
decade. The federal government has
established a $800 million, 4-year, primary
care fund to accelerate the transition to new
primary care models.
1. A YEAR IN THE LIFE OF CANADA’S HEALTH CARE SYSTEM
Science and
Technology
Forge Ahead
Events unfold rapidly in the laboratory
and at the bedside regardless of the nature
and pace of system reform. In the past
year, there have been new findings and
new controversies.
In some cases, researchers have forged
new ground. The revolution in genetics and
molecular biology continues unabated.
Stem cell research, generating new cells
from embryonic and adult tissue, was big
news in 2002. Some argue that this type of
research holds enormous promise for
advances against diseases, such as multiple
sclerosis, diabetes, and Parkinson’s. Others
suggest that it creates ethical dilemmas
when the embryo is the main building block
for the research and when cloning of cells
becomes part of the scientific or therapeutic
agenda. In response, the Canadian
Institutes of Health Research published
guidelines10 and the federal government
pledged to pass legislation on stem cell
research.11 It appears likely that the ethical
debate and the scientific opportunities will
continue to confront each other well into
the future.
Scientific debate simmered in other areas
as well, revealing, yet again, that some
clinical issues are inherently complex and
difficult to resolve. For example, the ongoing mammography debate flared up in
response to a Danish review that suggested
the procedure was less effective than
conventionally thought.12 The study was
widely discussed and firmly challenged.13
The Canadian Cancer Society continues to
advocate mammography for women aged
50-69. Its American counterpart has
advocated screening for women over 40.
And a consensus panel recently convened
by the World Health Organization
reviewed the literature in this area and
concluded that mammography does
reduce the risk of dying from breast
cancer by about 35% in women aged 50
to 69, but that it offers only a slight benefit
in younger women. This year’s report
profiles current levels of screening and
other issues in Chapter 3: Public Health:
On Guard Year After Year.
Other technologies, such as
transplanting islet cells, are on the
horizon. Islet cells produce insulin, helping
the body use glucose for energy. If these
cells do not produce enough insulin, a
person develops diabetes. Pancreatic islet
cell transplantation is being explored as a
possible long-term treatment option for
diabetics. However, while early results look
promising, further research is required to
determine long-term health outcomes.
More Changes
to Come….
Health care will almost certainly continue
to develop and change over the coming
years. Some of these changes might come
from on-going research on health, health
services, and health outcomes. Others may
come in response to recent reports.
Already, this process has started. And more
reports—as well as probably more
changes—are coming.
The rest of this year’s report focuses on
current healthcare trends and the latest
data and research. Our hope is that, in the
weeks and months ahead, this information
will provide a solid basis to support sound
health policy, effective management of the
health system, and public awareness of
factors that affect health.
9
HEALTH CARE IN CANADA 2002
For More Information
Fyke KJ. (2001). Caring for Medicare: Sustaining a Quality System. Saskatchewan: Commission on
Medicare.
2
Commision d’étude sur les services de santé et les services sociaux. (2000). Emerging Solutions:
Report and Recommendations. Quebec City: Government of Quebec. www.cessss.gouv.qc.ca
3
Premier’s Advisory Council on Health. (2001). A Framework for Reform.
www.premiersadvisory.com
4
Canadian Health Services Research Foundation. (2001). Listening for Direction: A National
Consultation on Health Services and Policy Issues. www.chsrf.ca/docs/pconsult/frpt_e.shtml
5
Chan TB. (2002). The declining comprehensiveness of primary care. Canadian Medical
Association Journal, 166(4), 429-434.
6
Ehman AJ, Sullivan P. (2001). South Africa appeals to Canada to stop recruiting its MDs.
Canadian Medical Association Journal, 164(3), 387-388.
7
Lomas J, Woods J, Veenstra G. (1997). Devolving authority for health care in Canada’s provinces:
An introduction to the issues. Canadian Medical Association Journal, 156(3), 371-377.
8
Hutchison B, Abelson J, Lavis J. (2001). Primary care in Canada: So much innovation, so little
change. Health Affairs, 20(3), 116-131.
9
First Ministers Meeting. (2000, September 11). Communiqué on Health (News Release). Ottawa:
Canadian Intergovernmental Conference Secretariat.
10
Canadian Institutes of Health Research. (2002). Human Pluripotent Stem Cell Research: Guidelines
for CIHR–Funded Research.
www.irsc.gc.ca/publications/ethics/stem_cell/stem_cell_guidelines_e.shtml
11
Debates of the Senate (Hansard). (2002, March 12). Status of the Legislation to Address Human
Tissue and Stem Cell Research. 1st session, 37th Parliament, 139 (95). www.parl.gc.ca
12
Olsen O, Gøtzsche PC. (2001). Cochrane review on screening for breast cancer with
mammography. The Lancet, 358(9290), 1340-1342.
13
Miettinen OS, Henschke CI, Pasmantier MW, Smith JP, Libby DM, Yankelevitz DF. (2002).
Mammographic screening: no reliable supporting evidence? The Lancet, 359(9304), 404-405.
1
10
Part A: Inside Canada’s Health
Care System
They call it “Internet time”. The rapid development of the
Key Dates in Canadian
web means that yesterday’s science fiction—instantly
sending a message to your friend in Venezuela or
Health Care Policy
scanning the world’s vast medical literature in mere
• 1867: British North American Act establishes the
basis for provincial responsibility for hospitals.
seconds—is today’s reality.
• 1947: Saskatchewan introduces Canada’s first
A description of Canada’s current healthcare system would
publicly funded universal hospital insurance
probably have seemed equally far-fetched when the first
program.
hospital opened in Quebec City in 1639. The founding
• 1958: The federal government passes the Hospital
religious order offered a range of services, from making and
Insurance and Diagnostic Services Act. All provinces
dispensing medicines to surgery. One surgeon was on staff—
and territories were covered under the cost-sharing
program for hospital insurance by 1961.
a barber from France.
• 1966: The federal Medical Care Act introduces
A century later, people living in larger communities in
federal/provincial cost-sharing for physician services
Upper Canada and the Maritimes who could afford to were
outside hospitals. By 1972, all provinces/territories
likely to call on doctors to treat smallpox, influenza, typhoid,
are participating in the program.
and other conditions. The poor often relied on home
• 1974: Marc Lalonde, the federal health minister,
remedies or sought help from charities.
releases a report called A New Perspective on the
Health of Canadians. It reinforces the idea of broad
By the mid-19th century, the first medical schools were
determinants of health (including human biology,
open. So were general hospitals in Montreal and Toronto.
the environment, lifestyle choices, and health care
These hospitals depended on charitable organizations and
organization) and calls for a reorientation of
the rich for donations. Patients often paid little or nothing
healthcare services toward health promotion.
for their care. The Ontario government began paying
• 1977: The Established Programmes Financing Act
annual grants to the Toronto General after a lack of funds
introduces a program of federal transfers that are
not directly tied to the costs of the
closed the hospital for a year in the 1870s.
provincial/territorial programs.
By the mid-1900s, general improvements in living and
• 1984: The Canada Health Act reinforces the basic
working conditions and public health efforts meant
principles provinces and territories must meet to
Canadians were much less likely to die from infectious
qualify for federal health funding (public
diseases. In 1947, Saskatchewan became the first province
administration and operation, comprehensiveness,
to introduce a publicly funded, universal hospital insurance
universality, portability, and accessibility). It
outlaws out-of-pocket charges for services covered
program. Saskatchewan also led the way in insuring
under the Act.
doctors’ services—in 1962. Within a decade, all provinces
• 1996/1997: The federal contribution to health and
and territories had followed Saskatchewan’s lead. Today,
social services is consolidated into the Canada
each administers insurance plans guided by common panHealth and Social Transfer, a major change in
Canadian principles.
federal provincial/territorial cost-sharing
And yet, the more things change, the more they remain
arrangements for health services.
the same. Many of the core challenges we face today would
be familiar to time-travelers from the past. Part A of this report highlights
updated information on what is and is not changing in the complex web of
health services that makes up today’s healthcare system.
2. CARE AND CARING
2. Care and Caring
How Healthy are Canadians?
For anyone under 30, Canada before Medicare is history—
something learned about secondhand from grandparents’
stories, history books, or TV documentaries. Almost four in ten
Canadians were born after 1972 when the last of the
provinces and territories joined the series of insurance plans
that cover most hospital and physician services.
Today, all jurisdictions administer interlocking publicly funded
insurance plans guided by common pan-Canadian principles.
The federal government is directly responsible for some
healthcare services for specific groups. These include the Royal
Canadian Mounted Police, members of the armed forces,
veterans, status Indians and Inuit, and inmates in federal jails.
Other types of health care are funded through a complex mix
of public funding, private insurance, and out-of-pocket
payments. Examples include drugs, home care, nursing homes,
dental care, physiotherapy, and alternative therapies.
Percent reported
The winds of change swept through Canada’s health care
system throughout the 20th century. But one thing that hasn’t
changed is that health is affected by much more than health
care. Many factors—where and how we grow up, live, and
work; the air we breathe; the food we eat; how much we
smoke and exercise; our levels of stress, social support and
feelings of isolation, to name just a few—also affect our
health and well-being.
Life expectancy at birth in Canada is excellent, among the
highest in the world. By 1997, it was about 79 years,1 up
from 59 years in the early 1920s and 69 years in the 1950s.2
And compared with 20 years ago, older adults can (on
average) look forward to a better quality, as well as a
longer life.3
But not everyone has the same chances for a long and
healthy life. For example, the life expectancy of women (81
years in 1996) was almost six years higher than for men.
Significant gaps—over 10
years—also occur from region
What Canadians Say About Their Health
5
to region across the country.1
Most Canadians (61%) rated their health as very good or excellent on the 2000/2001 Canadian
Differences also exist in how
Community Health Survey. Many health regions had rates that were about the same as the national
Canadians rate their own health. average (shown by the solid line on the chart below). But some had significantly lower or higher
rates. The regional rates (shown by the circles) are estimated to be accurate to within the range
Just over six in ten Canadians
shown by the bars 19 times out of 20. Results for all regions across the country are available in
aged 12 and older (61%) said
Health Indicators 2002, an insert in the back of this report.
that their health was very good
80
or excellent on the 2000/2001
Canadian Community Health
75
Survey. Who was more likely to
70
be in this group? According to
65
the survey:
• Younger compared to older
60
people.
55
• People with higher incomes
50
and education levels.
• People without chronic
45
conditions compared to
40
people with at least one.
35
Zone 1, NS
Côte-Nord, QC
Zone 3, NS
Moncton area, NB
Fraser Valley, BC
Vancouver/Richmond, BC
Bas-Saint-Laurent, QC
Outaouais, QC
Gaspésie-Îles-de-la-Madeleine, QC
Abitibi-Témiscamingue, QC
Regina, SK
Zone 5, NS
Muskoka, Nipissing, P. Sound & Timiskaming, ON
Fredericton area, NB
Northwestern Ontario
Simon Fraser (includes Burnaby), BC
Algoma-Cochrane-Manitoulin & Sudbury, ON
Northern Interior, BC
South Okanagan Similkameen, BC
Saint John area, NB
Grand River, ON
East Central, AB
Lakeland, AB
South Fraser Valley, BC
Saskatoon, SK
Mauricie et Centre-du-Québec,QC
Edmonton, AB
Grey-Bruce-Huron and Perth, ON
Montréal-Centre, QC
Central Vancouver Island, BC
Chinook, AB
Estrie, QC
Chaudière-Appalaches, QC
Essex-Kent and Lambton, ON
Winnipeg, MB
Hamilton-Wentworth, ON
David Thompson, Central AB
Simcoe-York, ON
Region de Québec, QC
Quinte-Kingston and Rideau, ON
Laval, QC
Montérégie, QC
Thompson, BC
Calgary, AB
Upper Island/ Central Coast, BC
Niagara, ON
Capital, BC
Champlain (Ottawa area), ON
Toronto, ON
Lanaudière, QC
PE
Durham-Hal.-Kawartha & Pine Ridge, ON
Zone 6, NS
Laurentides, QC
Waterloo-Wellington-Dufferin, ON
North Okanagan, BC
Eastern, NF
Thames Valley, ON
Halton-Peel, ON
Saguenay-Lac-Saint-Jean, QC
Central, NF
St. John's area, NF
North Shore, BC
30
Source: Canadian Community Health Survey, Statistics Canada
i
HEALTH CARE IN CANADA 2002
Medicare—and Other
Care—Today
The web of healthcare services touches
Canadians at home, work, and school; in
physicians’ offices, pharmacies, community
health centres, hospitals, and nursing
homes; and in many other places. Ideally,
this complex network of healthcare
providers and organizations should work
together to provide high quality care,
where and when needed, across the land.
In 2000/2001, most Canadians (78% of
those aged 12 and older) reported that
they had consulted a family doctor at least
once in the last year. Many also sought
care from other health professionals.
Consultations with dentists/orthodontists
(60%), eye specialists (38%), and other
medical doctors (28%) were among the
most common.
Seeking Care
6
Most Canadians aged 12 and older (78%) said that they had
consulted a general practitioner at least once in the year prior
to the 2000/2001 Canadian Community Health Survey. The
graph below shows the proportion who reported having
consulted selected types of health care providers, including
complementary and alternative practitioners.
Many Canadians also visit healthcare
institutions in the course of a year. These
institutions come in all sizes and shapes—
from large teaching hospitals to
rehabilitation centres, chronic care
facilities, nursing homes, and outpost
nursing stations.
Most hospitals offer short-term diagnostic
and treatment services for patients with a
wide range of illnesses and injuries. Some
also have separate groups of beds, wings,
or buildings devoted to long-term care.
Other hospitals specialize in treating
particular groups of patients, such as
children, mothers giving birth, and patients
with cancer or psychiatric conditions.
Overnight stays in hospital have become
less common in recent years, but day
surgery programs are growing. Canadians
spent almost 21 million days as inpatients
Stays In Hospital
7
Canada’s acute hospitals discharged 2.9 million in-patients
in 1999/2000 (excludes newborns and patients in other types
of care such as emergency wards, chronic care and
rehabilitation units, and day surgery programs). Age
standardized rates of hospitalization—based on where the
treatment occurred, not where the patient lived—varied across
the country, as shown below.
NF
General Practitioner
PE
Dentist/Orthodontist
NS
NB
Eye Specialist
QC
Other Medical Doctor
ON
Chiropractor
MB
Consultation for Mental or
Emotional Health
SK
Massage Therapist
AB
Homeopath, Naturopath
BC
YT
Acupuncturist
NT
0%
10%
20%
Note: Consultations for mental or
emotional health may occur with a variety
of professionals, including family doctors,
psychiatrists, psychologists, social workers,
and counselors.
30%
40% 50% 60%
% of respondents
Men
70%
80% 90%
Women
Source: Canadian Community Health Survey, Statistics Canada
14
NU
CAN
0
50
100
150
Acute care hospitalizations per 1000 population
200
Source: Hospital Morbidity Database, CIHI
2. CARE AND CARING
i
in acute care hospitals in 1999/2000, down
15.6% from 1994/1995. Heart disease and
stroke (15% of hospitalizations), pregnancy
and childbirth (14%), and digestive
diseases (11%) were the three leading
causes of inpatient hospitalization in
1999/2000. In contrast, more and more
patients received day surgery over this fiveyear period. For example, the number of
day surgeries grew by 18% in Ontario.4
Most Canadians were hospitalized in the
health region where they lived. The
likelihood of an inpatient acute hospital
stay close to home in 1999/2000 varied
depending on what care you needed and
where you lived. For example, patients who
received relatively common types of
surgery, like a hysterectomy, were less likely
to leave their health region than were
patients who had more specialized
procedures, like bypass surgery. Health
Indicators 2002 (located at the back of this
report) includes inflow/outflow ratios for
each of Canada’s largest health regions.
• Those with one or more chronic
conditions (23% versus 13% of others)
• Canadians with more education or
higher incomes
Using Natural Health Products
8
More than 7 in 10 of Canadians reported using one or more
natural health products (NHP) in the past six months in March
2001. The rates for selected types of products shown below
are estimated to be accurate to within 2 percentage points,
19 times out of 20.
Vitamins
Herbal remedies
Iron, calcium, mineral supplements
March 2001
May 2000
Food, other supplements
March 1999
Homeopathic remedies
other NHP
0%
10%
20%
30%
40%
50%
60%
70%
% of Respondents
Choosing Other Options
More and more Canadians are using
massage therapy, traditional Aboriginal
and Chinese medicine, homeopathy,
herbal products, and other healing
practices and products in addition to, or
instead of, conventional medical treatment.
In 2000/2001, about 4.9 million
Canadians aged 12 and older (19%)
reported seeing a chiropractor or another
type of complementary or alternative
health care provider in the previous year.
That is up from 14% in 1994/1995.
Who is most likely to consult with
complementary and alternative health
practitioners? According to the Canadian
Community Health Survey:
• Women (21% versus 17% for men)
• Canadians in mid-life (23% of those
aged 25 to 54 compared with 14% aged
12-24 and 16% aged 55 and older)
Source: Berger E. (2001). The Berger Population Health Monitor. Toronto.
Caring for Ourselves
and Our Families
Professionals play important roles in promoting health and caring for
the sick. So do individual Canadians. The 2000/2001 Canadian
Community Health Survey asked Canadians in most parts of the country
(excluding Quebec, Manitoba, and Nova Scotia) what, if anything, they
had done in the past year to improve their health.
About half (54% of those aged 12 and older) said that they had
taken action. Increasing physical activity was the most common step
taken (57%). Weight loss was next (13%), followed by changes in diet
or eating habits (12%) and quitting or reducing smoking (7%). About
4% said that the change they made was to seek medical treatment.
Younger people, those with more education and higher incomes, and
women were more likely to report having made a change.
Many adult Canadians—about one in four in 2000—also reported
providing some form of care to someone inside or outside their home.5
The proportion of Canadians providing care and the types of care they
gave differed by age, sex, and other factors. For example, 32% of
Canadians aged 45-64 years reported providing informal care.
15
HEALTH CARE IN CANADA 2002
What Canadians
Think…
What do Canadians think about the care
they receive and the system as a whole? A
recent review commissioned by CIHI found
that some type of patient or public
satisfaction measurement is underway in
most parts of the country. Many health
regions and hospitals, for example,
conduct patient satisfaction surveys.
Satisfaction with the Alberta
Health Care System
9
In 2001, three out of four Alberta residents (76%) said that
they were “very satisfied” or “somewhat satisfied” with the
health care system in Alberta. According to the report, men
tended to have higher levels of satisfaction than women did.
60%
50%
% of Respondents
40%
Across the many surveys and projects,
some findings are consistent; others differ.
Clearly, measuring satisfaction with
healthcare is complex. In part, that is
because a wide range of factors, including
the measurement tools used, can affect
how people rate health care. For example,
how and what questions are asked may
affect peoples’ opinions. Different types of
people also tend to respond differently,
even when asked exactly the same
questions. For example, in a recent
Ontario report, seniors gave the highest
satisfaction ratings for hospital care. Men
were also more likely than women to give
higher satisfaction ratings for such things
as process quality, global quality, and
housekeeping. In addition, many surveys
find that respondents give higher ratings to
the care they or their families received than
to the healthcare system in general.
Untangling the Evidence—Satisfaction
with Care and Services
10
The results of studies of satisfaction with health care and services
are sometimes difficult to interpret, partly because of variations in
the methods and data sources used. The table below outlines
some of the key differences between selected recent Canadian
satisfaction studies. (Note that, in most cases, even where the
underlying concept being measured—such as overall satisfaction
with the healthcare system—was the same, questions or
populations surveyed differed, making comparisons difficult.)
30%
20%
10%
0%
Very Satisfied
Somewhat Satisfied
1999
Neither
2000
Somewhat Dissatisfied
Very Dissatisfied
2001
Source: Northcott HC. (2001). The 2001 Survey About Health and the Health System in Alberta.
Alberta: University of Alberta, Population Research Laboratory.
Different groups also periodically
conduct broad-based polls of the general
public. As part of the response to an
agreement by premiers and the prime
minister in 2000, Statistics Canada recently
asked Canadians across the country about
their satisfaction with care. Results will be
available in the fall of 2002.
16
Source: Compiled by CIHI
2. CARE AND CARING
What Nurses Think
Measuring how satisfied healthcare professionals
are with their jobs is as complex as tracking patient
satisfaction with care. Once again, many factors are
involved and how you measure satisfaction levels can
affect results.
New research suggests that nurses who report
being satisfied with their jobs also feel that they are
providing better care.6 The study also found that
nurses who felt that a lower quality of care was being
provided were more likely to report higher levels of
job pressure, job threat, and role tension.
Job Satisfaction of Hospital Nurses:
An International Perspective Heart Surgery
11
A 1998/1999 survey of RNs in five countries found that most
were satisfied with their present jobs. But levels of satisfaction
varied from country to country, as shown below. Note: the
Canadian sample included nurses from Alberta, British
Columbia, and Ontario only. The United States sample
included only nurses from Pennsylvania.
Germany
care but didn’t receive it. Most said no, but
about 3.2 million adults (13%) agreed. This
compares to 6% in 1998/1999. Of the
13%, half (50%) said that their reasons
related to the availability of care, including
long wait times. Other reasons included
being too busy, transportation problems,
not knowing where to go, or deciding not
to seek care. Seven percent of those
reporting perceived unmet needs chose to
do without health care. Their reasons
included competing demands on their
time, attitudes towards illness, and issues
related to health care providers or the
healthcare system.
Declining Comprehensive Primary Care
12
In Ontario, the proportion of “office-only” general practitioners
and family physicians rose from 14% to 24% between
1989/1990 and 1999/2000. These “office-only” physicians
tended to be females, recent graduates, physicians aged
65 years and older, and those practicing in a city with a
medical school. “Office only” physicians were less likely to be
rural physicians or those certified in family medicine.
Scotland
80
70
% of GPs/FPs Providing Service
England
90%
Source: Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, Giovannetti P, Hunt J,
Rafferty AM, Shamian J. (2001). Nurses’ reports on hospital care in five countries.
Health Affairs, 20(3).
…About Access to Care
In addition to overall measures of
satisfaction, researchers often ask more
focused questions. Several recent surveys
have explored what Canadians think about
their access to care.
In 2000/2001, Statistics Canada asked
adult Canadians (aged 12 and older)
whether, in the past year, there was ever a
time when they felt that they needed health
10
0
In-patient Hospital
Nursing Home
House Calls
Anesthesia
Emergency
Office Only
1999/2000
80%
1998/1999
70%
1997/1998
60%
1996/1997
50%
1995/1996
40%
1994/1995
30%
% of Respondents Satisfied with Their Present Job
1993/1994
20%
20
1992/1993
10%
30
1991/1992
0%
40
1990/1991
US
50
1989/1990
Canada
60
Obstetrics
Source: Chan BT. (2002). The declining comprehensiveness of primary care. Canadian Medical
Association Journal, 166(4), 429-34.
17
HEALTH CARE IN CANADA 2002
waiting periods is difficult; so is judging the
Provincial surveys have asked similar
impact of anxiety, missed work, pain, or
questions. For example, about 65% of
Albertans said that access to care was easy other consequences that a patient may
experience while waiting.
or very easy in 2001, almost unchanged
7
Wait times are affected by many factors.
from 2000. Researchers also asked which
Examples include individual characteristics
services were most difficult to access. For
such as the severity of illness, the urgency of
those reporting difficulty, just over 12%
need, and the expected benefits of
indicated hospital admission and surgery
treatment.8 Others are broader system
(about the same as in 2000); almost 47%
said general practitioners (up from 41% in
factors: the availability of doctors, other
2000); and 35% said medical specialists.
health professionals, and health care
In general, people with higher perceived
resources (e.g. operating time); referral
levels of need were more likely to report
patterns; and where a patient is to be
difficulties in accessing services.
treated can affect wait times. The number
Just over 11% of Albertans surveyed said
that they had
personally been
When Do Waiting Times Begin?
unable to obtain
One
of
the
main
challenges in comparing wait times is deciding what ‘wait time’ means.
healthcare services
Should a wait be calculated from when someone first experiences pain or other symptoms? From
when needed in
when he/she first visits a family doctor? From when test results confirm the need for further
2001. Of these
treatment? From some
individuals, almost
other point? There are
When is a Waiting Time Really
13
advantages and
a quarter (22%)
a Waiting Time?
disadvantages
to
each
reported never
One of the reasons that it is so hard to compare data from
approach. And the choice
getting the service.
across the country, is that there are many possible ways to
made can affect results.
define wait times. No one decision is “correct.” But these
Why? Thirty-nine
differences must be understood if meaningful comparisons are
percent said that it
to be made. The figure below shows a possible care path, with
was because wait
a variety of options for calculating wait times.
times were too long; 26% said that they
could not get an appointment to see a
Recovery
health professional; and 7% said that the
First symptoms
services were not available nearby or were
Surgery
not conveniently located.
Decide to seek care
Watching the Clock:
Wait Times in
Health Care
In some cases, a delay of minutes
counts. For example, a patient who is
bleeding severely needs emergency care.
Similarly, research suggests that there is a
short window of time within which patients
with acute ischemic strokes benefit most
from thrombolytic (clot-busting) therapy.
But often, waiting is not immediately life
threatening. Determining medically safe
18
Decide on
surgery
Assessed by
family doctor
Re-assessed by specialist
Decide on
non-surgical treatment
More tests
Assessed by
specialist
=When the clock might start
= When the clock might stop
Referred to
specialist
Tests
2. CARE AND CARING
of factors potentially involved means that it
is often hard to disentangle just what caused
which parts of someone’s wait for care.9
Comparable data about who is waiting
for what, for how long, and the factors that
influence waiting are scarce. Different
groups monitor wait times in different
ways. Some ask patients who received
treatment in a given period how long they
waited for care. Information on observed
patient experience can also be collected
directly from medical records or specialized
monitoring systems.
An alternative approach is to survey
doctors and ask them how long they
expect that a patient would wait for a
particular type of care. A review by the
Canadian Health Services Research
Untangling the Evidence—Wait Times
14
The results of wait time studies seem contradictory, partly
because of variations in the methods and data sources used.
The table below outlines some of the key differences between
selected recent Canadian wait list studies and registry
information. In addition, while most studies using administrative
data include all patients who received care, coverage for
physician surveys varies. For example, only about one quarter of
doctors contacted by the Fraser Institute in 2001 responded to
the survey.
Study
Based on Patient Experience
New Brunswick
NB, NS & Ontario
data from
Discharge Abstract
Database
Cardiac Care
Network of Ontario
Manitoba Centre
for Health Policy
Alberta Health &
Wellness
Performance
Indicators
B.C. Surgical Wait
List Registryó
Provincial Trends
Physician Surveys
Fraser Institute
Commonwealth
Fund Survey of
Physicians
Data source/
Coverage
Regional Hospital
Corporation
surgical wait lists
Actual patient
experience
reported by
hospitals
Actual patient
experience
reported by
hospitals
Actual patient
experience based
on physician fee for
service claims
Regional Health
Authorities (joint
replacement);
Alberta Cancer
Board
General finding
Wait(s) measured
Time period
5.5% more cases waiting at end of
March 1999 vs. 1998
# patients waiting, not
wait times
March 1996-99
Waits fluctuate throughout the year
and are longest in the winter
Time spent in ER after
health professional
determined patient
should be admitted
Surgery booking to
surgery
March 2000-April 2001
Little change in 5-year period, stable
or decreased for six of eight
procedures.
From last pre-operative
visit with surgeon to
surgery date
1992/93 to 1996/97
Waits vary across regions, with some
below and others above provincial
targets
Quarterly Reports 2001
Actual patient
experience
reported by
hospitals
Survey of physician
opinion on
reasonable waits
Survey of physician
opinion on
expected waits
Waits have fluctuated up and down
over the last 5 years; waits for some
types of care were up, others down in
most recent 6 months
Actual waits were often longer than
respondents considered reasonable in
2000-2001 in most parts of Canada
Expected hip replacement waits
shorter in Canada than in Australia,
New Zealand, and the UK, but longer
than in the US
Prescription to first
treatment for radiation
and chemotherapy;
decision or booking of
surgery to surgery for
joint replacement
Surgery booking to
surgery
GP visit to specialist,
specialist to treatment
1991-2001
Not specified
April ñ July 2000
Regional differences, but in all areas
urgent/emergent patients have much
shorter waits than elective patients
November 2001-January
2002
June 1995 ñ June 2001
approach may best measure care
providers’ satisfaction with access times.
Comparisons between approaches are
difficult because of the differences in
definitions used. For many areas where
reasonably close comparisons are
possible, wait times reported using the first
approach appear to be shorter than those
based on the second.
A Sample of What’s Tracked
Across the country, there are growing
pockets of information about who is
waiting for what and for how long. We
have profiled many of these efforts in
previous reports, but new initiatives
continue to emerge. This year, we again
highlight a sample of wait time
information available from recent or ongoing monitoring programs.
For example, a recent study in Quebec
tracked changes in wait times from first
diagnostic procedure to breast cancer
surgery between 1992 and 1998.
Researchers found that median wait times
increased substantially over this period,
from 29 to 42 days. This was true even
after adjusting for differences in age and
cancer stage at diagnosis. Researchers
found that the two most important factors
contributing to wait times were the number
of diagnostic procedures before surgery
and the stage of the cancer at diagnosis.11
Ontario researchers are also tracking
cancer wait times.12 They looked at waits
experienced by breast, gynecologic,
colorectal, head and neck, thoracic, and
urologic cancer patients selected over a
four-month period and treated by
surgeons affiliated with regional cancer
centres. Researchers found that wait times
varied by cancer type, but not substantially
by the age of the patient.
Source: Compiled by CIHI
Foundation (CHSRF)10 suggests that this
19
HEALTH CARE IN CANADA 2002
Ontario Wait Times for Open Heart Surgery
15
Wait times for open heart surgery vary across Ontario. In
2000/2001, at St. Michael's Hospital the median wait time-the
point at which half of all patients had longer waits and half
had shorter waits-was 55 days for elective open heart surgery.
That compares to 17 days at Sudbury Regional and at
Kingston General. Across all hospitals, emergency and urgent
patients had a median wait of 2-5 days. Across Ontario, the
median wait time for elective open-heart surgery was 38 days
in 2000/2001; for urgent surgery it was 3 days.
60
Median Wait Time (days)
50
40
30
20
10
St. Michael's (Toronto)
University Health Network
(Toronto General)
Sunnybrook and
Women's College HSC
London HSC - Victoria and
University campuses
University of Ottawa
Heart Institute
Hamilton HSC General Campus
Trillium Health Centre
(Mississauga)
Kingston General
Sudbury Regional Memorial Site
0
In the Emergency Department
Crowded emergency departments (EDs) continued to make the
headlines in several parts of the country in the past year. How busy an
ED is depends on how many people come to the ED, how sick they are,
what happens in the emergency department, how many beds are
available in the hospital, what other types of care are available in their
community, and other factors.
A 1999 poll13 asked Canadians who had visited an emergency
department in the last six months how long they waited before seeing a
physician. Almost half (49%) said that they had waited less than an
hour. In contrast, 9% waited more than four hours; and 1% left before
seeing a physician. Older patients (65% of those 55 years and older)
were more likely to report seeing a physician within an hour.
Another side of the story is presented when individuals are asked how
they felt about their wait in the emergency department. A recent survey of
Ontario patients14 found that 78% of those polled said they were satisfied
with the amount of time they waited in order to receive treatment.
Most patients who come to the ED go home after they receive care,
but others need to be admitted to an inpatient bed. Hospitals in several
provinces now track how long patients wait in the emergency
department after a health professional decides that they need to be
admitted. The median wait time for three Canadian provinces, (Nova
Scotia, New Brunswick, and Ontario) was 90 minutes in 2000/2001.
Hospital
Elective
Emergency & Urgent
Waiting for a Bed
Source: Cardiac Care Network of Ontario. (2002). Patient Access to Care.
www.ccn.on.ca/access/waittimes.html
Surgical Wait Times in British Columbia
16
British Columbia maintains a computerized registry documenting
surgical volumes and wait times reported by hospitals. This
database covers 95% of all of surgeries booked by referring
physicians in British Columbia. Wait times are calculated from
the booking date to the surgery date for all surgeries performed
in the three months prior to reporting date. Ophthalmology and
orthopedic surgery have the longest median wait times; general
and gynecology surgeries have the shortest.
12
17
How long do people wait in an emergency room once it has
been determined they should be admitted to hospital? For
2000/2001, comprehensive data are available for 3 provinces
(New Brunswick, Nova Scotia, and Ontario). Over 80% of
patients waited under 6 hours for a bed. Only 3% waited
longer than 24 hours. In general, wait times were longer in the
winter months.
Waited More than 24 Hours
3%
Waited Between 12 to 24 Hours
8%
Waited Between 6 to 12 Hours
7%
Waited Less than 1 Hour
36%
10
Median Wait (weeks)
8
Waited Between 1 to 6 Hours
46%
6
4
Source: Discharge Abstract Database, CIHI
2
0
Jun-98
Dec-98
General Surgery
Jun-99
Ophthalmology
Dec-99
Jun-00
Gynecology
Dec-00
Orthopedics
Jun-01
Urology
Source: BC Surgical Wait List Registry (2001). Provincial Trends.
www.healthservices.gov.bc.ca/waitlist/provdata.html
20
2. CARE AND CARING
Information Gaps—Some Examples
What We Know
• Life expectancy in Canada is among the best in the world, but there are important
differences among regions of the country and population groups.
• Most Canadians report having consulted a family doctor in the last year. Many also
use a mix of other healthcare services. The number of Canadians consulting
complementary and alternative care providers appears to be increasing.
• Public confidence in Canada’s healthcare system varies across the country. In many
surveys, respondents report being more satisfied with the services that they personally
received than with health services in general. Most Canadians rate the care they have
recently received as excellent or very good, although trends differ across the country.
• There are pockets of information on wait times for different types of care across
the country.
What We Don’t Know
• What types of services do hospital emergency departments and outpatient clinics
provide? How well is the changing mix of hospital services meeting community needs?
• How does patient satisfaction with hospital care and other types of services compare
across the country? What factors explain higher and lower satisfaction levels?
• How do wait times compare across the country? What percentage of wait times fall
within recommended guidelines for different treatments? What is the emotional and
physical impact of waiting for different types of care?
What’s Happening
• The recent Canadian Community Health Survey offers a wealth of new information
about the types of care that Canadians in different parts of the country report
receiving.
• Canada’s premiers and the prime minister agreed to track and report on patient
satisfaction and wait times, along with 12 other indicator areas, in each of their
jurisdictions by 2002.
• The pockets of wait time data are expanding. For example, Saskatchewan Health is
developing a provincial waiting list information system that will cover approximately
93% of the surgeries done in the province.15 At a pan-Canadian level, CIHI launched
the Canadian Joint Replacement Registry in 2000 in collaboration with orthopedic
surgeons from across the country. As part of this project, partners are working
towards collecting comparable wait times for total hip and knee replacements.
• The Western Canada Waiting List Project brought together major stakeholders in
1999 to develop reliable, valid, practical, and clinically transparent tools to prioritize
patients waiting for cataract surgery, children’s mental health services, general
surgery, hip and knee replacement, and MRI scans.16 A report on the project’s results
was issued in March 2001. The Ontario Waiting List Project is also evaluating some
of these tools.17
21
HEALTH CARE IN CANADA 2002
For More Information
1
Statistics Canada. (2001). Health Indicators: Life Expectancy. Ottawa: Statistics Canada.
http://www.statcan.ca/english/freepub/82-221-IE/01201/hlthstatus/deaths.htm#life
2
Statistics Canada. (2002). Canadian Statistics: Life Expectancy at Birth. Statistics Canada,
Catalogue 82F0075XCB.
3
Chen J, Shields M. (1999). Health in Mid-life. Health Reports, 11(3), 35-46. Catalogue 82-003-XPB.
4
Canadian Institute for Health Information. (2001). Hospital Report 2001: Acute Care. Ottawa: CIHI.
5
Berger E. (2000). The Berger Population Health Monitor. Toronto: The Hay Group.
6
McGillis Hall L, Irvine Doran D, Baker GR, Pink GH, Sidani S, O’Brien-Pallas L, Donner G. (2001).
A Study of the Impact of Nursing Staff Mix Models and Organizational Change Strategies on
Patient, System and Nurse Outcomes: A Summary Report of the Nursing Staff Mix Outcomes Study.
Toronto: University of Toronto, Faculty of Nursing.
7
Northcott HC. (2001). The 2001 Survey About Health and the Health System in Alberta.
Edmonton: University of Alberta, Population Research Laboratory.
8
Hadorn DC and the Steering Committee of the Western Canada Waiting List Project. (2000).
Setting priorities for waiting lists: Defining our terms. Canadian Medical Association Journal,
163(7), 857-60.
9
Olivotto IA, Bancej C, Coel V, Snider J, McAuley R, Irvine B, Kan L, Mirsky D, Sabine MJ, McGilly
R, Caines JS. (2001). Waiting times from abnornal breast screen to diagnosis in 7 Canadian
provinces. Canadian Medical Association Journal, 165(3), 277-83.
10
Canadian Health Services Research Foundation (CHSRF). (1998). Quid Novi? 1(4). Ottawa:
CHSRF.
11
Mayo NE, Scott SC, Shen N, Hanley J, Goldberg MS, MacDonald N. (2001). Waiting time for
breast cancer surgery in Quebec. Canadian Medical Association Journal, 164(8), 1133-8.
12
Simunovic M, Gagliardi A, McCready D, Coates A, Levine M, DePetrillo D. (2001). A snapshot of
waiting times for cancer surgery provided by surgeons affiliated with regional cancer centres in
Ontario. Canadian Medical Association Journal, 165(4), 421-5.
13
Berger E. (2001). The Berger Population Health Monitor. Toronto: The Hay Group.
14
Hospital Report Research Collaborative. (2001). Hospital Report 2001: Emergency Department
Care. Toronto: Hospital Report Research Collaborative, University of Toronto.
15
Saskatchewan Health. (2000). Saskatchewan Health Annual Report 2000-01.
www.health.gov.sk.ca/Report.pdf
16
Western Canada Waiting List Project. (2001). From Chaos to Order: Making Sense of Waiting
Lists in Canada. www.wcwl.org
17
Ontario Joint Policy and Planning Committee. (2000, November 10). Ontario Waiting List Project
Launched. www.jppc.org/owl/news_rel1.htm
22
3. THE PEOPLE, THE COST, THE INFORMATION
3. The People, the Cost,
the Information
Health care is a large, resource-intensive industry. More than 1.5 million
Canadians worked in health care and social services in 2000. And we now
spend over $102 billion dollars per year on health services (2001 forecast). This
chapter explores the human, financial, and information resources used to deliver
care to Canadians across the country.
Canada’s Health Care Professionals
18
Together, registered nurses (RNs), licensed practical nurses
(LPNs), and registered psychiatric nurses (RPNs) account for
more than one-third of all health care workers. The rest come
from a wide variety of occupations. The chart below shows the
number of health professionals per 100,000 Canadians in
2000 for selected occupations.
The People
About one in ten employed Canadians
worked in health care and social services in
2000.1 Many provide care directly to patients.
Others serve in support roles, teach, do
research, manage health programs, or have
other responsibilities. In addition, many more
Canadians helped to care for friends and
family members or volunteered with health
care organizations.
Denturists
Cardiology Technologists
Medical Sonographers
Other Health Diagnosing and Treating Professions
Chiropractors
Optometrists
Dental Technicians
Midwives
There’s More: Report on the
People Who Work in Health
Care in Canada
The Distribution of Health Personnel
Opticians
Respiratory Therapists
Dietitians/Nutritionists
Nurses†
36%
Occupational Therapists
Audiologists
Dental Hygienists
CIHI has recently released a special report that
includes more in-depth information about Canada’s
health care providers. Information in this report covers
the supply and distribution of health care providers,
educational trends, migration, the
composition and characteristics of
the health care team, recruitment
and retention issues, the health
and worklife of health
professionals, and much more.
The report can be downloaded for
free from www.cihi.ca.
Other
56%
Psychologists
Medical Radiation Technologists
Ambulance Attendants
Physiotherapists
Medical Laboratory Technologists
Physicians
8%
Dentists
Registered Psychiatric Nurses*
Medical Laboratory Technicians
Pharmacists
Dental Assistants
Social Workers
Health Record Administrators/Technicians
Physicians
Licensed Practical Nurses*
Nurse Aides/Orderlies
Registered Nurses**
0
100
200
300
400
500
600
700
800
# of health professionals per 100,000 population
Notes: Registered Psychiatric Nurses are only registered in
British Columbia, Alberta, Saskatchewan, and Manitoba;
therefore the ratio for this group is calculated using the
population of these four provinces only.
† Includes RNs, LPNs, and RPNs
Sources: Labour Force Survey, Statistics Canada except where noted.
* Health Personnel Database, CIHI ** Registered Nurses Database, CIHI
HEALTH CARE IN CANADA 2002
Nursing is the largest health profession.
Nurses work in a wide range of settings—
including providing crisis care in busy
emergency rooms, acute care on hospital
wards, palliative care in long-term care
facilities, and community care in homes.
They may also assist new mothers in their
homes or promote public health policies
such as smoke-free public places. In
addition, nurses do research in universities,
work in home care, and much more. There
are three regulated nursing groups:
registered nurses (RNs), licensed practical
nurses (LPNs)*, and registered psychiatric
nurses (RPNs).
Nurses Across the Country
19
In 2000, 752 registered nurses (RNs) per 100,000 Canadians
were employed in nursing along with 207 licensed practical
nurses (LPNs) per 100,000 Canadians. But nursing to
population ratios varied across the country, as the map
below shows.
752
207
CAN
908
451
787
NA
PE
767
160
YT
NF
NT/NU
681
122
BC
731
135
AB
838
151
SK
876
203
MB
695
225
795
210
ON
NS
923
329
Sources: Registered Nurses Database, CIHI; Health Personnel Database, CIHI
* Licensed practical nurses are also known as registered practical nurses and
registered nursing assistants in different parts of the country.
20
The number of registered nurses per 100,000 population fell
in most parts of the country between 1994 and 2000.
Exceptions were Newfoundland and Labrador, Prince Edward
Island, and the Yukon (which saw ratios rise), as well as
Saskatchewan (which saw little change over this period).
1200
1000
800
600
400
200
NF
PE
NS
NB
QC
ON
1994
*Notes: Manitoba LPN data are estimated.
LPN data are not available from the Yukon.
RN and LPN data for Northwest Territories and Nunavut are not separated for the two
territories. Accordingly, the same ratio (calculated using combined population figures) is
reported for both jurisdictions.
24
Trends in Nursing Supply
0
QC
NB
960
294
RN
LPN
1,006
535
In 2000, more than 232,000 RNs
worked in nursing in Canada. That’s up
more than 5 registered nurses per
100,000 Canadians from 1999, but down
35 per 100,000 population from 1995.
Although most RNs (64% in 2000) still
work in hospitals, the number employed in
community health is gradually increasing.
There were also more than 63,000 LPNs
and 5,400 RPNs working in Canada in
2000. Registered psychiatric nurses are
licensed only in the four western provinces.
# of RNs per 100,000 population
Canada’s Nurses
MB
SK
AB
BC
YT
NT/NU
CAN
2000
Source: Registered Nurses Database, CIHI
3. THE PEOPLE, THE COST, THE INFORMATION
Nursing in Rural and Small Town Canada
Canada’s rural areas and small towns were home to about 22% of the total population in 2000, including about
18% of registered nurses employed in nursing. That’s a total of 41,502 RNs or 623 per 100,000 population in rural
Canada. In urban areas, the rate is 780 per 100,000 Canadians.
Between 1994 and 2000, population growth was accompanied by decreases in the number of RNs employed in
nursing in urban and rural areas. As a result, the nurse to population ratio has declined in both types of regions.
These ratios are useful starting points. But they do not fully explain variations in the supply of nursing services.
Differences in geography and distance, the types of work that nurses do, practice patterns, and the context within
which nurses work must also be taken into account. A new program of research is beginning to explore these factors,
and many other issues.
Early results2 suggest that, in general, RNs who live in rural and small town Canada share many characteristics
with their city counterparts. For example, the RN workforce is aging; fewer than one in 20 RNs is male; the average
level of RN education is rising; and most RNs provide direct patient care.
Within these overall trends, there are important differences from community to community. For instance, 22 rural
communities are served by a sole RN, aged 60 or older. Another 93 have a single RN aged 50–59 years. In contrast,
some rural communities have much younger nurses. A sole RN under the age of 30 is in place in 54 communities.
There are also some areas where trends differ between rural and urban areas. For example, RNs in rural and
small town Canada are more likely to work for more than one employer. They are also
more apt to have overlapping roles (e.g. management/administration and direct patient
care). Migration patterns also differ. For instance, rural RNs are more likely to have
stayed in the province where they were first trained than their urban colleagues. As for
other types of immigrants, foreign-trained nurses tend to work in urban areas.
Watch for more results from the Nursing Practice in Rural and Remote Canada Study
Group over the coming years.
Physician Trends
After nursing, medicine is the second
largest regulated health profession. In
2000, CIHI counted more than 57,800
physicians in clinical and non-clinical
practice in Canada, up 5.3% since 1996.
During this period, the number of
specialists grew more (7.4%) than did the
number of family doctors (3.2%). As of
2000, specialists accounted for just under
half of all physicians (49.6%).
Growth patterns differed across the
country. Between 1996 and 2000, the
Northwest Territories had the largest
estimated increase in the number of
physicians per 100,000 population (+25).
Nova Scotia (+14), Saskatchewan (+10),
Manitoba (+8), and Newfoundland (+7)
also saw substantial growth. In Alberta†,
Quebec, British Columbia, New Brunswick,
†
and Prince Edward
Island, the
increases were
smaller. While
physician rates increased in the majority of
the country, they were relatively stable in
Ontario (-1) and fell in the Yukon (-10).
Between 1999 and 2000 Nunavut also
experienced a decrease (-15).
The absolute numbers of licensed
physicians is one important factor in
understanding physician supply. There
are also many others. For example, many
physicians perform duties other than
clinical care, such as administration,
teaching, and research. As a result, it is
important to consider the number of
physicians providing different types of
services, not just the total number
with licenses.
Due to recently identified reporting issues this estimate was under review at the time of publication.
25
HEALTH CARE IN CANADA 2002
Other factors—such as gender, age,
specialty, size of community, place of
graduation, clinical demands, average
workload, and personal characteristics—
can also influence the “effective” physician
supply. For instance, a recent report3
found that 15-20% of physicians receiving
fee-for-service payments for clinical
services are “inactive” for at least 3 months
of the fiscal year. This situation is more
common among women physicians and
those in rural areas.
Despite periods of inactivity, however,
average physician workloads are
increasing.3 In fact, the workload of
physicians—as measured by activity
ratios—has increased since 1993/1994 in
primary care, medical, and surgical
specialties.
What’s in an Activity Ratio
“Activity ratios” compare the relative amount of
work two group of physicians do, as measured by feefor-service activity, taking into account which
provinces they practice in and their specialties. For
example, a ratio of 1.0 represents what a “typical”
full-time physician billed (technically, between the
40th and the 60th percentiles), adjusted for differences
between provinces and specialties.3
Care Providers of the Future
Graduates from today’s training
programs are tomorrow’s health care
providers. The numbers and types of
graduates will have substantial effects on
the future of our health care system.
More women than men work in health
care. The characteristics of students
enrolled in university programs suggest
that this pattern will continue. In
1998/1999, Statistics Canada reported
that about 37,500 students were enrolled
in full-time and part-time undergraduate
health professional programs. Over threequarters (76%) were women.4
26
Recently announced increases in
enrolment for some health professional
programs may swell these numbers in the
coming years. For example, British
Columbia plans to nearly double its
enrolment capacity of first year medical
students from 128 to 224 by 2005.5 They
are also planning to establish satellite
medical schools in Prince George and
Victoria for the new Northern and Island
Medical Program. Last year, Ontario
announced similar plans. They propose to
admit 55 students to a new northern
medical school with sites in Sudbury and
Thunder Bay in 2004.6 Current Ontario
medical schools can also enroll 47 more
students this year on top of 113 new
placements offered in 2000 and 2001.
Some postgraduate programs are also
growing. For instance, to improve the focus
on northern/rural practice, 25 new firstyear postgraduate positions and 25 new
third-year family medicine positions are
now available.7 Finally, the government is
also opening the door for 15 Canadian
citizens or landed immigrants who
completed their training outside of Canada
to undertake postgraduate training before
starting to practise in Ontario.8
Medicine isn’t the only growth area. For
example, Prince Edward Island and
Newfoundland and Labrador have added
14 and 32 new seats (respectively) for
nursing studies.9,10 Some educational
institutions are also offering programs that
allow nursing students to graduate sooner,
by condensing studies for those with
previous degrees or allowing students to
fast-track by taking summer courses.
3. THE PEOPLE, THE COST, THE INFORMATION
Rising Tuition Costs
21
Medical and dental programs have higher average
undergraduate tuition than other types of programs—and they
have seen steeper increases since 1998/1999. The chart
below shows average undergraduate tuition fees per year by
program type. Using the most current enrolment data
available, averages are weighted by the number of students
enrolled at each university per program.
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2,000
Arts
Science
Law
Medicine
2001/2002
2000/2001
1999/2000
1998/1999
1997/1998
1996/1997
1995/1996
1994/1995
1993/1994
1992/1993
0
1991/1992
1,000
1990/1991
Today’s students are facing rising health
education costs. Average annual tuition fees
at Canadian universities have increased
steadily in recent years.11 That’s true at both
the undergraduate and graduate levels and
for most types of programs. For example,
the average annual tuition fees for dentistry
programs rose from $5,425 to $8,491
(a 57% increase) between 1998/1999 and
2001/2002.12 Over the same period,
tuition for medical students increased 39%.
In 2001/2002, their average tuition
was $6,654.
Use of student loans and debt levels
are also rising. According to Statistics
Canada’s National Graduate Survey, 50%
of new university health graduates‡ in 1995
had government student loans, compared
to 47% in 1986.13 The median amount
owed by university health grads also rose
over this period, from almost $9,300 to
$15,000, adjusted for inflation. So did the
proportion of health grads turning to other
funding sources, such as families, friends,
and other financial institutions, to finance
their education (from 18% in 1986 to 22%
in 1995).
Different types of health graduates
reported different levels and types of student
debt. Nursing graduates were less likely to
have borrowed money through government
loans or other sources in 1995 than others
were. In contrast, growth in use of funding
sources other than student loans was higher
for medical students§ than for other health
grads. In 1995, 48% reported their use, up
from 27% in 1986.
A separate 2001 survey14 found that firstyear medical students in Ontario (where
tuition has more than doubled since 1997)
expected to have higher debt levels than did
fourth-year students. First-years expected to
owe a median of $80,000 at graduation
compared with $57,000 for fourth-years.
Average domestic tuition fees ($)
The Cost of Studying
Dentistry
Note: Average values shown above are not adjusted for inflation.
Between 1990 and 2001, the Consumer Price Index increased by 25%.
Sources: Tuition and Living Accommodation Costs Survey, Culture, Tourism, and the Centre
for Education, Statistics Canada
Passing the Torch
Children born to poorer, less educated parents tend to have different education and career patterns than those from other families.15,16,17,18 In
the 1995 National Graduate Survey, more than half of all health graduates (52% from university and 65% from college programs) reported that
their father had a high school education or less. Results were similar for maternal education. Parents of nursing grads were more likely to be in
this group (approximately 65%) than those of medical school grads (approximately 39%).
A 2001 survey of first-year students in Canadian medical schools outside Quebec19 found that respondents differed from the Canadian
population as a whole in several ways. For instance, more were from visible minority groups, although some groups were over-represented and
others were under-represented. Students were also less likely to come from rural areas (11% versus 22% of the population in general) and from
families and neighbourhoods with low socioeconomic status. For example, they reported that 39% of their fathers and 19% of their mothers had
a master’s or doctoral degree. That compares with 6.6% of Canadian men aged 45 to 64 and 3% of women in this age group.
‡
§
Only includes graduates that did not complete further post-secondary education prior to the interview.
Includes graduates from the professional program, and the medical and surgical specialty programs.
27
HEALTH CARE IN CANADA 2002
They were also more likely to say that
their financial situation would have a major
influence on which specialty they would
choose and where they would practice
after graduation. Similar gaps were not
found among students surveyed at
Canadian medical schools outside of
Ontario. (Quebec was not included in
the study)
Managing Health Care
in Canada
Most health professionals provide direct or
indirect services to patients. Others organize
the delivery of services. Who is managing
our health system? Although comparatively
little is known about these professionals and
how their ranks are changing over time,
pockets of information do exist.
For example, the University of Ottawa,
the Canadian College of Health Services
Executives and Caldwell Partners worked
together on a national survey of Canada’s
health care CEOs in January 2000.20 The
survey asked executives to describe
themselves, their recent career, and their
perceptions of health system change.
Over 100 CEOs responded to the survey
(response rate of 32%). The majority of
respondents were
• between the ages of 45-54 (57%);
fewer than two percent were under age
35 and fewer than 10% were over the
age of 60
• male (87%)
• educated at the Master’s degree
level (71%)
Many CEOs reported job changes in
recent years; 39% had been in their current
role for three years or less. Another 20%
had between three and five years tenure
and just under a quarter (23%) had between
five and 10 years.
CEOs of health organizations also
frequently work with ministries of health and
politicians. Again, relatively little is known
about these groups except in pockets where
special studies have been done.
Quebec’s Health Care Managers
In 2001, Quebec’s Ministry of Health and Social Services released a report that profiled the 9,593 managerial staff in the health network
and outlined the challenges associated with their recruitment and retention.21 The report anticipates that many health care managers will
retire in the next ten years. At the same time, changes in the health care system may affect the demand for managers. The report calls for
human resources transition planning since 23% of executives are
approaching retirement age—almost double the rate for other
Changes at the Top
23
Since 1990, 85 health ministers and 79 deputy ministers of
management positions.
Health and Social Services
Managers in Quebec
22
A recent report by Quebec’s Ministry of Health and Social
Services profiled the more than 9,500 middle, senior, and top
managers in the province’s health sector. The table below
highlights some of their findings. For example, while almost
two-thirds (63%) of middle managers are women, men hold
almost eight in ten (78%) of the top positions.
health have served at the federal, provincial, or territorial level
across the country. The table below shows the number of
ministers and deputy ministers who held office in each
jurisdiction between January 1990 and December 2001 and
their median term (in months). The median is the point at which
half served longer and half served shorter terms.
Notes :
* Includes Chief Executive Officers, Managing Directors, Assistant Managing
Directors, Executive Advisors
** Includes Directors, Assistant Directors, Assistants to the Managing Director, etc.
Source: Ministère de la Santé et des Services Sociaux. (2001). Planification de la main-d’oeuvre Personnel cadre et hors-cadre du réseau de la santé et des services sociaux. Rapport du conseil
d’administration du Centre de référence des directeurs généraux et des cadres. Québec. MSSS.
*Approximate value (the year of appointment is the only information available for some
deputy ministers).
Source: Compiled by CIHI
28
3. THE PEOPLE, THE COST, THE INFORMATION
Dividing the Health Care
Dollar: Who Pays?
Many groups share the cost of health
care. The federal, provincial, territorial, and
municipal governments, as well as social
security programs, pay part of the cost. Just
under $2,400 per person came from these
public sector sources in 2001. That’s about
73% of the total. The rest came from
private sources, such as insurance
companies and out-of-pocket payments.
Between 2000 and 2001, public sector
spending grew faster than that from private
sources. After adjusting for inflation and
population growth, it was up about 5.7%,
compared to 0.7% for the private sector.
The increases continue recent trends. In
1997, just under 30% of health spending—
the highest proportion seen over the last
quarter century—came from the private
sector. Each year since then, growth in
spending from the public purse outpaced
that from private sources. The reverse was
true from 1992 to 1997.
24
Canadians spent about $3298 per person on health care in
2001 (the equivalent of about $3089 in constant 1997
dollars). CIHI estimates that inflation-adjusted public sector
health care spending per person increased by just under 6%
compared to 2000. Private sector health care spending growth
was lower—under 1%.
2,500
2,000
1,500
1,000
500
0
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000f
2001f
Canada’s health care spending is higher
than ever before. It passed the $100 billion
mark for the first time in 2001. In total, we
spent $102.5 billion (forecast) to improve or
maintain our health, an average of about
$3,300 per person.
After adjusting for inflation and population
growth, total health care spending was up
4.3% from the year before. Annual increases
in health care costs are the norm in Canada.
We have seen steady growth over several
decades, except for the mid-1990s.
Population growth and inflation partly
explain this trend. But even after they are
taken into account, spending in 2001 is
expected to have been more than 80%
higher than in 1975. And real health care
spending per person on average rose faster
over the last four years than in any period
since Medicare was introduced.
Who Spends What on Health Care
Constant (1997) $ per capita
Spending on
Health Care
Public
Private
Note: Open symbols are forecast figures.
Source: National Health Expenditure Database, CIHI
How Canada Compares
Canada spends more of its economic
output on health care than most countries.
For example, we spent about 9.3% of GDP
on health care in 1998. Only three OECD
countries spent more—the United States
(12.9%), Switzerland (10.4%), and
Germany (10.3%).22
What about actual dollars spent on
health care? In total, we spent more per
person than 25 of the other 29 OECD
countries in 1998, after adjusting for
differences in exchange rates and prices.
At an international level, higher spending
is not necessarily tied to better health. For
example, the United States consistently
spends more on health care than Canada
but has a lower life expectancy.
In all countries, the health care bill is
divided between public and private sector
payers. Although the public sector share in
the United States (45% in 1998) is lower
than in all other OECD countries, it
29
HEALTH CARE IN CANADA 2002
nonetheless reflects for high expenditure.
For example, United States public sector
spending per person on health in 1998
($1,866 US) was higher than total public
plus private spending in more than half of
all OECD countries. Other OECD
members spent between 46% (Korea) and
92% (Luxembourg) publicly. In US dollar
terms adjusted for differences in
purchasing power across countries, the
range of public spending per person was
$201 in Mexico to $2,087 in Switzerland.
Canada came in at $1,655, higher than
all but 7 other countries.
As in Canada, public health care
spending in most countries has fluctuated
in recent years. Some commentators
suggest that unpredictable changes in
spending from year to year may make it
difficult for those responsible for delivering
health services to plan appropriately.23
A Closer Look at Canada
Within Canada, the health care bill
varies from coast to coast. Among the
How Much We Spend
25
North to south, east to west, Canadians everywhere spend
substantial amounts per person on health care. Overall, public
sector health care spending per person averaged $2,396 in
2001 (forecast). Average private sector spending was $902
per Canadian.
$2396
$902
provinces, total public and private spending
per person ranged from about $2,899 in
Quebec to $3,630 in Manitoba in 2001. As
in previous years, per capita spending was
highest—over $4,000—in the territories.
Why does health spending vary? Many
factors—geography, health needs, how
care is organized and delivered, and how
much health professionals are paid,
among others—can affect expenditures.
For example, the territories serve relatively
small populations scattered over large
geographic areas. This partly explains their
higher health expenditures. In 1999, for
instance, 12% of their public health care
dollars went to ambulance services. The
provinces averaged less than 2%.
Differences in demographics can also
affect health costs. Average expenditure is
different for men and women, the young
and the old. To better understand these
effects, CIHI “standardizes”
provincial/territorial government health
care expenditures for differences in age
and sex.24 The results estimate what the
government would have spent if its
residents had the same age/sex profile as
the country as a whole.
Where Government Health Dollars Go
26
The types of health care we need change over our lifetime. The
chart below shows how much provincial/territorial governments
spent per person on different types of health care by age group
in 1999.
CAN
$16,000
$3438
$761
YT
$5145
$379
$5171
$427
PE
NU
NF
NT
$2632
$908
BC
$2501
$826
AB
$2579
$716
SK
$2550
$695
$2724
$906
MB
$2363
$1072
$2186
$713
Spending per capita
$14,000
$2181
$878
$12,000
$10,000
$8,000
$6,000
$4,000
QC
$2,000
ON
$0
<1
1-4
5-14
15-44
45-64
65-74
75-84
85+
Age group
NB
$2306
$760
Public
Private
NS
$2279
$950
Source: National Health Expenditure Database, CIHI
30
Hospitals
Other institutions
Physicians
Other professionals
Retail drug sales
Other
Source: National Health Expenditure Database, CIHI
3. THE PEOPLE, THE COST, THE INFORMATION
In 1999, provincial government spending
on health care ranged from $1,747 per
person in Prince Edward Island to $2,194 in
Newfoundland. That’s a difference of almost
26%. The gap was even wider—almost
35%—after estimates were age/sex
standardized. Why? On average,
Newfoundland’s population is younger than
Canada’s as a whole and Prince Edward
Islanders are older. As is the case for the
unadjusted figures, per capita standardized
spending was highest in the Territories.
Health’s Share of Government Dollars
27
Health care is only one of many programs that provincial and
territorial governments fund each year. Its share of the total,
however, is rising. It was almost a third (32%) of total
expenditures including debt charges in 2000, up from 27% in
1975. The map below shows health care spending as a
percentage of total provincial/territorial government
expenditures for each jurisdiction in 2000.
of Household Spending**, Canadian
households are spending more on health
care than in the past. Average spending
per household in 2000 was $1,357, up
from $1,009 in 1996. The largest share
was for health insurance premiums,
followed by medicinal and pharmaceutical
products and dental services.
How Household Health Care
Spending is Changing
28
In 2000, Canadian households, on average, spent $1,357 on
health care. That represents just over 3% of after-tax spending.
Between 1996 and 2000, average household after-tax
spending on health care rose in all provinces. The graph below
compares the change in average household health care
spending across the country over this period, adjusted for
differences in age, sex, and household composition. In all
cases, differences between 1996 and 2000 are statistically
significant (p<0.05). The dollar value beside each province
shows average household spending on health care in 2000.
NF ($1,131)
PE ($1,261)
NS ($1,328)
NB ($1,306)
QC ($1,359)
ON ($1,194)
MB ($1,261)
26%
15%
YT
19%
NU
17%
NT
34%
BC
31%
AB
PE
31%
NF
SK ($1,325)
AB ($1,907)
BC ($1,501)
31%
SK
32%
MB
CAN ($1,357)
QC
ON
36%
26%
0%
5%
10%
15%
20%
25%
30%
% Change between 1996 and 2000
NB
28%
NS
31%
Note: Direct health care expenditures by the federal government, which tend to be highest on
a per capita basis in the territories, are not included. Total Provincial and Territorial
Government includes expenditures by sovereign and non-sovereign bodies of provincialterritorial ministries, departments and agencies; autonomus boards, commissions and funds;
and autonomous non-commercial non-profit education, health and social service agencies
controlled by provincial-territorial governments.
Source: National Health Expenditure Database, CIHI
As taxpayers, we contribute to public
spending on health care. In addition, we
pay health insurance premiums and out-ofpocket health care costs. These two
categories account for the bulk of private
spending on health care.
According to Statistics Canada’s Survey
Notes: Based on full-year households only.
Data from the territories are not available.
Due to differences in provincial health plans, average household spending
may include provincial health care insurance premiums in some jurisdictions.
Source: Family Expenditure Survey, Statistics Canada (1996).
Survey of Household Spending, Statistics Canada (2000).
Spending patterns varied depending on
age, sex, living arrangements, and other
factors. For example, male seniors living
alone in 1999 reported spending an
average of $744 on health care. Their
female counterparts said they spent
more—an average of $873. In contrast,
men under age 65 reported spending
$594 in 1999. That compares with $840
for women in the same age group.25
** The Survey of Household Spending collects self-reported data on household expenditure. Average spending per household is higher than the average
per person numbers reported above from CIHI’s National Health Expenditure Database.
31
HEALTH CARE IN CANADA 2002
Health care spending also differed by
household income. To see how, we divided
households into five groups of equal size
(called “quintiles”) based on their annual
income. The highest income group spent
more than three times as much on health
care as the lowest income households,
adjusted for household size. But the lowincome group spent a larger share of its
after tax-income on health care in 2000
(3.9% versus 2.6%). Across all households,
3.1% of after-tax income went to health
care, up from 2.3% in 1978.26
The Difference Income Makes
29
High-income and low-income Canadian households tend to
have different spending patterns. That’s as true for health care
as for other goods and services. In 2000, households with
incomes of $21,216-$37,000 (the second quintile) had the
highest percentage of after-tax spending on health care, after
adjusting for differences in age, sex, and household
composition. However, in actual dollars spent, households in
the highest quintile spent the most on health care in 2000.
Today, many (such as cataract or hernia
surgery and treatment for kidney stones)
can often be done safely and less
expensively on an outpatient basis. Today’s
distribution of health care spending reflects
these and other changing patterns of care.
In 1975, almost half of all health care
spending in Canada (45%) went to
hospitals. At more than $32 billion, it was
still the largest single category of spending
in 2001. That’s just over $1,000 per
Canadian—up an estimated 4% from
2000. Nevertheless, hospitals’ share of
total health spending continued to fall. It
was 32% in 2001.
Where our Health Dollar Goes
45%
Second Quintile:
$21,216–$37,000
Second Quintile:
$21,216–$37,000
40%
Lowest Quintile:
Less than $21,216
Lowest Quintile:
Less than $21,216
Overall
Overall
1%
2%
3%
4%
5%
% of After-Tax Spending on Health Care
Spending on Health Care
Notes:Based on full-year households only.
Data from the Territories are not available.
Due to differences in provincial health plans, average household spending
may include provincial health care insurance premiums.
% of total health care spending
Third Quintile:
$37,000–$55,760
$2,500
Third Quintile:
$37,000–$55,760
$2,000
50%
$1,500
Fourth Quintile:
$55,760–$82,402
$1,000
Fourth Quintile:
$55,760–$82,402
$500
Highest Quintile:
$82,402 and over
$0
Highest Quintile:
$82,402 and over
35%
30%
25%
20%
15%
10%
Source: Survey of Household Spending, Statistics Canada.
5%
The organization and delivery of health
care has changed over the last 25 years.
So has the way we spend health care
dollars. Two decades ago, most surgeries
required an overnight stay in hospital.
32
Hospitals
Physicians
Drugs
2001f
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
0%
1977
Dividing the Health
Care Dollar: Where the
Money Goes
1975
0%
30
The way we spend health care dollars has changed significantly
over the last 25 years. Although hospitals still account for the
largest single portion of health care spending, their share has
dropped over time. In contrast, spending on drugs first exceeded
that on physician services in 1997. It has remained higher every
year since. The chart below shows the percentage distribution of
the top four categories of health care spending from 1975 to
2001. Together, these categories accounted for just under 72%
of total public and private health spending in 2001.
Other Professionals
Notes: The “other professionals” category includes the services of privately practicing
dentists, denturists, chiropractors, massage therapists, orthopedists, osteopaths,
physiotherapists, podiatrists, psychologists, private duty nurses, and naturopaths.
Data for 2000 and 2001 are forecast figures.
Source: National Health Expenditure Database, CIHI
3. THE PEOPLE, THE COST, THE INFORMATION
Physician services were the second
largest portion of the health care spending
pie twenty-five years ago, followed by other
health institutions, other health
professionals’ services, and then drugs.
Today, retail drug sales have overtaken
spending on physician services. They are
now the second largest health care
expense. For more information, see
Chapter 6, Medicating Illness: Drug Use
and Cost in Canada.
In 2001, physician services were the third
largest category of health expenditures.
Spending totaled just under $14 billion.
That translates to $446 per person, up just
over 6% from the year before. As a result,
physician services now account for 14% of
all health care dollars spent in Canada.
Another area that has seen substantial
changes in spending levels in recent years
is publicly funded home care. All provincial
and territorial governments fund some
home care services, but what is covered
varies throughout the country. In
1998/1999, Canadian governments spent
just under $3 billion on home care, up
significantly over the last decade.34
Why are home care costs going up?
Several factors are likely involved.
Possibilities include changing demands for
home care services; more reliance on home
care as an alternative to acute and longterm care hospitals; changes in informal
care availability; greater emphasis on selfmanaged care; and the changing mix of
private and public home care services.35
How Doctors Are Paid
Alternative payments as a % of clinical payments
Most Canadian doctors are paid on a fee-for-service basis. This means that every time a patient visits a doctor’s
office, the physician bills the ministry of health for the visit plus any additional services. Some doctors receive all of
their professional income on a fee-forservices basis. Others are paid in
Growing Popularity of Alternative
31
different ways.
Payment Plans
The mix varies across Canada. In
About $1 billion each year now flows to physicians through
Alberta, almost all physicians
“alternative” payment plans (other than fee-for-service
reimbursement). That’s about 11% of total clinical payments to
(estimated at 98% in 1998/1999) are
physicians in the ten provinces in 2000/2001.
paid only on a fee-for-service basis.
That compares to a low of 40% in
35
Manitoba.27
In 2000/2001, one in four Canadian
30
physicians received some payments for
clinical care through alternative
25
payment plans. Several recent reports
have called for expanded use of these
20
types of approaches as part of larger
15
strategies for reforming primary care
services. 28,29
10
New research is beginning to offer
insights into factors that might be
5
considered in designing alternative
30,31,32
For example,
payment plans.
0
Manitoba researchers recently studied
NF
PE
NS
NB
QC
ON
MB
SK
AB
BC
capitation funding models where a
1995/1996
2000/2001
physician receives a set amount per
Notes: Data for Newfoundland and New Brunswick from 2000/2001 were not
patient cared for. They noted the effect
available at the time of publication.
of different patient populations on
In Alberta, data from 25 Alternative Payment Program projects transferred to
Regional Health Authorities (not funded through Alberta’s medical services budget)
capitation funding models. 33
were not available.
Source: Complied by CIHI.
33
HEALTH CARE IN CANADA 2002
Growth in Home Care Spending
32
Spending on care provided in the home by health care workers
or through health programs supported by governments at the
provincial or community level is on the rise. Total provincial
home care spending increased by over 350% between
1988/1989 and 1998/1999. At the beginning of this period,
home care accounted for 1.6% of total provincial health
spending. By 1998/1999, it had risen to 4.7% of the total. The
graph below shows changes in spending by provincial
governments on home care per person over time. Data have
not been adjusted for inflation.
100
90
80
60
50
40
30
20
10
1998/1999
1997/1998
1996/1997
1995/1996
1994/1995
1993/1994
1992/1993
1991/1992
1990/1991
1989/1990
0
1988/1989
$ per capita
70
Source: Home Care Feasibility Study, National Health Expenditure Database, CIHI.
Who Uses Public Home
Care in Manitoba?
Researchers from Manitoba’s Centre for Health
Policy recently looked at the delivery of home care
services in their province.36 They found that home care
programs served just under 3% of the population in
1998/1999. The following groups were most likely to
have received public home care services:
• Older Manitobans
• Unmarried residents in all age groups
• Those who later entered a nursing home (93% in
1998/1999 received home care services prior to
their admission)
• Residents of poorer urban neighbourhoods who left
hospital or had outpatient surgery (compared with
residents of middle and upper-income
neighbourhoods).
34
Information: Another
Resource for Health
Human and financial resources are key
inputs to an effective health care system.
But they are not all that is important. This
year, we take a special look at information,
an increasingly important resource for
health and health care.
Our knowledge about health and health
care is expanding rapidly. Each year, about
400,000 new references are added to
MEDLINE, a database of biomedical
journals run by the US National Library of
Medicine. In this context, keeping up-todate with best practices and new
technologies in health care is a challenge.
One way of addressing this challenge is
to make better use of information and
communications technologies. In Canada,
as in other parts of the world, individuals
and health organizations are increasingly
moving in this direction. For example, all
provinces and territories are investing in
information systems to support health care
programs, although the pace of
implementation varies across the country.37
Health organizations and care providers
are also developing and using new
technologies, such as electronic health
records (EHRs). EHRs bring together—
under strict privacy and security protocols—
information about a patient’s various
contacts with the health care system. By
integrating information about a patient’s
medical history, hospital stays, laboratory
tests, drug prescriptions, and more, EHRs
aim to reduce duplication and improve the
quality, accessibility, portability, and
efficiency of care.37,38
Setting up electronic health records is
complex. Appropriate privacy safeguards,
standards for data exchange, information
systems, and other fundamental building
blocks are required. A number of groups
are working on these issues. For example,
many jurisdictions have passed legislation
3. THE PEOPLE, THE COST, THE INFORMATION
protecting the privacy of health
information. Already, many EHR-related
initiatives are moving forward in Canada
and elsewhere. For instance, just over
12% of Canada’s family doctors reported
that they were using EHRs on a 1999
survey by the College of Family Physicians
of Canada.39 More than a quarter believed
that they would be using EHRs within the
next five years.
What Doctors Think
33
In an international survey of physicians in 2000, about four
in 10 Canadian doctors felt that electronic medical records
would be “very useful” in improving quality of care. Among
the five countries surveyed, physicians in the United Kingdom
tended to be most positive about the quality-related benefits
of both electronic patient medical records and electronic
prescribing of drugs.
100
90
% of physicians stating “very useful”
80
70
60
50
40
30
20
10
0
Australia
Canada
New Zealand
Electronic prescribing of drugs
United Kingdom
United States
Electronic patient medical records
Source: 2000 International Health Policy Survey of Physicians, Commonwealth Fund.
Individual Canadians are also
increasingly accessing electronic sources
of health information, even though the
quality of information on the web is
variable.40,41 Statistics Canada’s
Household Internet Survey42 has found a
steady increase in the use of the Internet
for obtaining health information. Between
1998 and 2000, the proportion of
Canadians who reported using the web
for this purpose more than doubled from
10% to 23%. And more than half (57%) of
all households who regularly used the
Internet at home reported that they were
using it to obtain health information.
In another survey, most Internet users
reported going on-line to get information
about specific illnesses.43 Others used it for
different reasons. These included
diagnosing themselves, confirming or
disputing a physician’s diagnosis, checking
the results of medical studies, identifying
clinical trials for breakthrough treatments,
finding out more about specific prescription
drugs, or chatting with others with similar
health conditions.
Even though many Canadians are using
the Internet as a health information source,
a 2001 survey found that 7 in 10 would
still rather talk to their physician about their
health. And 43% of those surveyed would
consult their pharmacist for information
about their medications.44 Nevertheless, a
recent survey of patients at Toronto’s
University Health Network found that fewer
than half (48%) of those who retrieved
health information from the Internet
presented it to a health care professional.
Younger patients and those with higher
levels of education were more aware of the
Internet. Age and education also had an
impact on use of the Internet in general,
on obtaining health information, and on
the tendency to share the information with
care providers.45
It’s not only patients who are using the
Internet to access health information. In
2001, the Canadian Medical Association
reported that almost 80% of doctors were
using the Internet at their home or office.
Over 30% of those surveyed reported
referring patients to medical web sites on
an occasional basis.46
35
HEALTH CARE IN CANADA 2002
Information Gaps—Some Examples
What We Know
• The number of regulated health care providers and new health graduates in Canada
and how this has changed over time.
• How health care spending is changing over time.
• How spending in Canada compares to other countries.
• How much, on average, Canadian households spend on health care each year.
• The proportion of Canadian households using the Internet to access health-related
information.
What We Don’t Know
• Given demographic, workforce, health, health care and other trends, how does the
current combination of health care providers align with the health needs of the current
and future Canadian population?
• How might different mixes of public and private funding and service delivery
particularly in rapidly expanding areas such as home care and drugs affect costs,
access, quality and patient outcomes and satisfaction?
• What impact will changes in regulatory models and professional scopes of practice
have on the supply and distribution of health professionals, on our ability to meet
future health care needs, on how professionals organize and provide services, and on
the quality of care?
• How much is spent each year specifically on health promotion and prevention activities
in Canada?
• What are the effects on health and health care of increasing access by individual
Canadians and care providers to vast amounts of health information over the Internet?
What’s Happening
• A number of studies are underway at national, provincial/territorial, and local levels
to better understand health human resources issues.
• In January 2002, the provincial/territorial premiers committed to working with CIHI to
institute a pan-Canadian database on human resource needs, training requirements,
and scope of practice to assure a sustainable supply of health professionals.
• CIHI is conducting a feasibility study to separate public health (prevention and
promotion) programs and administration expenditures.
• Hospitals and community health services organizations will soon be able to better
capture dollars spent on information technology thanks to upcoming improvements
in the Management Information Systems Guidelines.
• Major projects are underway in most parts of the country to increase the use of
information and communications technologies, in an effort to improve health and
health care. These initiatives will, no doubt, be shaped by existing and emerging
legislation and guidelines on the protection of personal health information.
• The government of Canada has committed $500 million to Canada Health Infoway
Inc. (CHII). This funding is targeted to establish and accelerate the development and
adoption of modern health information systems and deployment of a pan-Canadian
electronic health record. Presently, a national registry of electronic health record
initiatives is being developed.47
36
3. THE PEOPLE, THE COST, THE INFORMATION
For More Information
Canadian Institute for Health Information. (2001). Canada’s Health Care Providers.
Ottawa: CIHI.
2
Canadian Institute for Health Information and Nursing Practice in Rural and Remote Canada.
(2002). Supply and Distribution of Registered Nurses in Rural and Small Town Canada, 2000.
Ottawa: CIHI.
3
Canadian Institute for Health Information. (2001). The Practicing Physician Community in Canada
1989/90 to 1998/99: Workforce and Workload as Gleaned through Billing Profiles for Physician
Services. Ottawa: CIHI.
4
Statistics Canada and Culture, Tourism and the Centre for Education Statistics. (2000). Education
in Canada, 2000. Ottawa: Statistics Canada. Catalogue 81-229-XPB
5
Government of British Columbia. (2002). B.C. doubles number of medical students. Information
Bulletin. http://os8150.pb.gov.bc.ca/4dcgi/nritem?5027
6
Government of Ontario. (2001, May 17). Harris Government Announces New Northern Medical
School and Increased Medical School Enrolment. Ontario: Government of Ontario Press Releases.
http://www.newswire.ca/government/ontario/english/releases/May2001/17/c5708.html
7
Council of Ontario Universities. (2002, January 26). What’s New in Health Sciences.
www.cou.on.ca/Health/Home/whatsnew.htm
8
Government of Ontario. (2002, February 13). Minister announces $800,000 to attract medical
students to Ontario. Ontario: Government of Ontario Press Releases.
http://www.newswire.ca/government/ontario/english/releases/February2002/13/c1474.html
9
Government of Prince Edward Island. (2001, June 18). Province and UPEI announce new nursing
seats at UPEI. PEI: Government of PEI New Release.
http://www.gov.pe.ca/news/getrelease.php3?number=2140
10
Government of Newfoundland and Labrador. (2002, March 21). Government to increase
enrolment in nursing program. Newfoundland: Government of Newfoundland and Labrador
http://www.gov.nf.ca/releases/2002/health/0321n30.htm
11
Statistics Canada. (2001, August 27). University tuition fees. The Daily. Ottawa: Statistics
Canada. http://www.statcan.ca/Daily/English/010827/d010827b.htm
12
Statistics Canada. (2002). Tuition and Living Accommodation Costs Survey (special data request).
Ottawa: Culture, Tourism, and the Centre for Education, Statistics Canada
13
Statistics Canada. (2002). National Graduate Survey (special data request). Ottawa: Culture,
Tourism, and the Centre for Education, Statistics Canada.
14
Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson IL. (2002). Effects of rising
tuition fees on medical school class composition and financial outlook. Canadian Medical
Association Journal, 166(8), 1023-1028.
15
Human Resources Development Canada (2000). Youth in Transition Survey: Project overview.
Ottawa: Applied Research Branch, HRDC.
http://www.hrdc-drhc.gc.ca/arb/publications/research/2000docs/t-00-5e.pdf
16
Human Resources Development Canada (1993). Who are the Leavers? In Leaving school:
Results from a National Survey Comparing School Leavers and High School Graduates 18 to 20
Years of Age. Ottawa: Applied Research Branch, HRDC. Catalogue MP43304/1993E
http://www.hrdc-drhc.gc.ca/arb/publications/books/class90/leaving/toc_e.shtml
17
Ryan BA , Adams GR. (1998). Family Relationships and Children’s School Achievement: Data from
the National Longitudinal Survey of Children and Youth. Ottawa: Applied Research Branch, HRDC.
Catalogue W-98-13E. http://www.hrdc-drhc.gc.ca/arb/publications/research/abw-98-13e.shtml
18
Way WL, Rossmann MM. (1996). Lessons from Life’s First Teacher: The Role of the Family in
Adolescent and Adult Readiness for School-to-Work Transition, National Center for Research in
Vocational Education, University of California, Berkeley. http://ncrve.berkeley.edu/abstracts/MDS-725/
19
Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. (2002). Characteristics
of first-year students in Canadian medical schools. Canadian Medical Association Journal, 166(8),
1029-1035.
20
Armstrong R, Brunelle FWH, Angus DE, Levac G. (2001). The changing role of Canadian Health
care CEOs: Results of a national survey. Health care Management Forum, Supplement.
21
Ministère de la santé et des services sociaux. (2001). Planification de la main d’oeuvre Personnel cadre et hors-cadre du réseau de la santé et des services sociaux. Rapport du conseil
d’administration du Centre de référence des directeurs généraux et des cadres. Québec : MSSS
22
Organized for Economic Cooperation and Development (2001). OECD Health Data 2001: A
Comparative Analysis of 29 Countries [CD-Rom]. Paris: OECD and CREDES.
1
37
HEALTH CARE IN CANADA 2002
Romanow RJ. (2002). Shape the Future of Health Care. Ottawa: Commission on the Future of
Health Care in Canada. http://dsp-psd.communication.gc.ca
24
Canadian Institute for Health Information. (2001). National Health Expenditure Trends, 19752001. Ottawa: CIHI.
25
Statistics Canada. (2001). Spending Patterns in Canada, 1999. Ottawa: Statistics Canada.
Catalogue No. 62-202-XPE.
26
Chaplin R, Earl L. (2000). Household spending on health care, Health Reports, 12(1), 57-63,
Catalogue No. 82-003-XIF.
27
Canadian Institute for Health Information. (2001). National Grouping System Categories Report
Canada, 1996/97 to 1998/99. Ottawa: CIHI.
28
New Brunswick Health and Wellness. (2002). Health Renewal, Report from the Premier’s Health
Quality Council. Fredericton: New Brunswick.
29
Alberta Health and Wellness. (2001). A Framework for Reform. Report of the Premier’s Advisory
Council on Health. Edmonton: Alberta Health and Wellness.
30
Hutchison B, Hurley J, Birch S, Lomas J, Walter S, Eyles J, Stratford-Devai F. (2000). Needs-based
primary medical care capitation: Development and evaluation of alternative approaches. Health
Care Management Science, 3, 89-99.
31
Hutchison B, Hurley J, Reid R, Dorland J, Birch S, Giacomini M, Pizzoferrato G. (1999).
Capitation Formulae for Integrated Health Systems: A Policy Synthesis. Hamilton: Centre for Health
Economics and Policy Analysis.
32
Godwin M, Shortt S, McIntosh L, Bolton C. (1999). Physicians’ perceptions of the effect on clinical
services of an alternative funding plan at an academic health sciences centre. Canadian Medical
Association Journal, 160, 1710-1714.
33
Menec V, Black C, Roos N, Bogdanovic B, Reid R. (2000). Defining Practice Populations for
Primary Care. Winnipeg: Manitoba Centre for Health Policy and Evaluation.
34
Canadian Institute for Health Information. (2001). Home Care Estimates in National Health
Expenditures—Feasibility Study. Ottawa: CIHI.
35
Canadian Home Care Human Resources Study. (2001). Phase 1 Highlights, Setting the Stage:
What Shapes the Home Care Labour Market? Ottawa: Canadian Home Care Human Resources
Study. www.homecarestudy.ca
36
Roos N, Stranc L, Peterson S, Mitchell L, Bogdanovic B, Shapiro E. (2001). A Look at Home Care
in Manitoba. Winnipeg: Manitoba Centre for Health Policy.
37
Office of Health and the Information Highway. (2001). Toward Electronic Health Records.
Ottawa: Health Canada.
38
Advisory Council on Health Infostructure. (1999). Canada Health Infoway, Paths to Better Health.
Ottawa: Health Canada.
39
Kazimirski M, Renaud C, Sawaya L, Zitner D, Korman R. (2000). Computer Literacy and Electronic
Medical Records. Toronto: The College of Family Physicians of Canada.
www.cfpc.ca/programs/online/_pdf/imssurvey.pdf
40
Jadad AR, Haynes B, Hunt D, Browman GP. (2000). The Internet and evidence-based decisionmaking: A needed synergy for efficient knowledge management in health care. Canadian Medical
Association Journal, 162(3), 362-5.
41
Jadad AR, Gagilardi A. (1998). Rating health information on the Internet.
Navigating to knowledge or to Babel? Journal of the American Medical Association, 279, 611-614.
42
Statistics Canada (2000). Household Internet Use Survey. Ottawa: Statistics Canada
43
Stuart N. (2001). Health care: The new economy’s last frontier? Health Care Management Forum,
14(3), 49-52.
44
Berger E. (2001). Population Health Monitor. Toronto: The Hay Group.
45
Dumitru C, Enkin M, Gauld M, Siqouin C, Catton P, Jones J, Jadad AR. (2002).
The impact of disease, ethnicity and education on the use of the Internet by patients in Toronto
(Unpublished Manuscript).
46
Canadian Medical Association. (2001). Physician resource questionnaire results. Canadian
Medical Association Journal, 165(5), 626.
47
Canada Health Infoway. (2002, January 31). Experience at the Helm of Canada Health Infoway.
Canada Health Infoway News Release. www.canadahealthinfoway.ca
23
38
Part B: In-Depth Reports
4. OUTCOMES OF CARE
4. Outcomes Of Care
“First do no harm” is a fundamental principle of medical ethics, carried
forward from ancient times. But how do we know what harm or good we do?
More than a century has passed since Florence Nightingale first used mortality
rates to vividly demonstrate how sanitary reforms dramatically cut deaths in the
Crimean War. On this side of the Atlantic, Ernest Codman, a physician,
challenged hospitals in 1910 to track patients to determine if their treatments
were effective.1
Measuring outcomes—and applying the results to continually improve care—is
an on-going challenge. This chapter highlights new findings for a number of
health conditions—heart attacks, stroke, asthma, transplants, and cancer. Further
details and other important health outcome data can be found in the Health
Indicators 2002 insert to this report, as well as on our Web site (www.cihi.ca).
The information presented here is an important start—and a significant
advance on the set of comparable outcome data that we had even last year. The
measures, such as survival rates following a diagnosis of cancer or how often
people need to return to hospital, are useful first steps, but they are still
incomplete. For example, they may tell us what happened, but not why it
happened. Better and more complete information is essential, not only for a
fuller understanding of the quality of care, but also for finding solutions to
problems. In different parts of the country and nationally, a number of focused
initiatives are underway or planned to address this challenge. We look forward to
continuing to work with partners across the country to advance these efforts.
Surviving A Heart Attack Or Stroke
Heart disease and stroke are major causes of illness, disability, and death in
Canada. Together, they accounted for 20.4% of male and 11.4% of female
hospitalizations in 1999/2000, according to CIHI data.
The care that these patients receive in hospital may affect their chances of
survival and their quality of life after they are discharged.2 So may many other
factors, not all of which are well understood. For example, research in Ontario
found that, after taking into account differences in age, sex, and the availability
of health services, people living in poorer neighbourhoods were less likely to get
some specialized treatments for AMI than those living in wealthier
neighbourhoods. They were also more likely to have died.3
i
HEALTH CARE IN CANADA 2002
Last year, CIHI found that 12.65% of
patients died in a hospital within 30 days
of an initial heart attack (or acute
myocardial infarction-AMI) hospitalization
in 1998/1999.4 We also calculated rates
for many of Canada’s largest health
regions. Our research showed that inhospital death rates varied from region to
region, although few regions’ rates were
statistically significantly different from the
overall average. To make rates as
comparable as possible, we adjusted for
regional differences in age, sex, and
comorbid conditions (illnesses present at
the same time as the heart attack). The
methods that we used have been welltested in Ontario and elsewhere.5
Research from Statistics Canada also
shows regional differences for one-year
mortality rates among heart attack patients
hospitalized in 1995/1996 for four
provinces (British Columbia, Alberta,
Saskatchewan, and Nova Scotia).
Differences were apparent even after
adjusting for age, comorbidity, and
revascularization procedure (i.e.
angioplasty and/or bypass graft). However,
there were fewer regional differences for
females than for males.6
Regional Variations in Mortality Following a Heart Attack
34
Across the country, 12.6% of patients died in hospital within 30 days of an initial hospitalization for a heart
attack between 1997/1998 and 1999/2000. Most regions had rates similar to this overall average but
some were statistically significantly higher or lower from the overall average, even after adjusting for age,
sex, and other co-existing illness. Available data covering this three-year period for regions with a
population of 100,000 or more are shown below. The rates (shown by circles) are estimated to be
accurate to within the range indicated by the vertical bars 19 times out of 20 (95% confidence interval).
The solid line represents the overall average of 12.6%.
20
Risk-adjusted 30 Day In-Hospital Mortality Rate (%)
18
16
14
12
10
8
6
4
2
Lakeland Regional Health Authority, AB
Capital Health Authority, AB
Calgary Regional Health Authority, AB
Chinook Regional Health Authority, AB
David Thompson Regional Health Authority, AB
Zone 6, NS
Winnipeg, MB
Toronto DHC, ON
Northwestern Ontario DHC, ON
Halton-Peel DHC, ON
Waterloo-Wellington-Dufferin DHC, ON
Quinte-Kingston and Rideau DHC, ON
Moncton and Area, NB
Saint John and Area, NB
Fredericton and Area, NB
Hamilton-Wentworth DHC, ON
PE
Simcoe-York DHC, ON
Grand River DHC, ON
Thames Valley DHC, ON
Grey-Bruce-Huron and Perth DHC, ON
Zone 5, NS
Durham-Haliburton-Kawartha and Pine Ridge DHC, ON
Saskatoon Service Area, SK
Regina Service Area, SK
Essex-Kent and Lambton DHC, ON
Zone 1, NS
Niagara DHC, ON
Champlain DHC, ON
Zone 3, NS
East Central Health Authority, AB
Algoma-Cochrane-Manitoulin and Sudbury DHC, ON
Muskoka, Nipissing, Parry Sound and Timiskaming DHC, ON
0
Note: Data from British Columbia, Newfoundland, and Quebec are not available due to differences in how hospital data are collected. For some
hospitals in Newfoundland, 1998/1999 data reported in last year’s report have been found to be not comparable and therefore should be disregarded.
Source: Hospital Morbidity Database, CIHI
42
4. OUTCOMES OF CARE
New for 2002
i
This year, we have moved forward in two
ways: computing AMI mortality rates over a
three-year period (not just a single year)
and, for the first time, calculating estimates
of 30-day in-hospital mortality following a
stroke for regions across the country.
Overall, 12.6% of patients died in a
hospital within 30 days of initially being
hospitalized for an AMI between
1997/1998 and 1999/2000.* Most
regions had mortality rates that were about
the same as this average, but some had
higher or lower rates. Similar to last year,
several regions in Alberta had lower riskadjusted mortality rates. Capital Health
Authority (Edmonton), Calgary, and
Lakeland all had rates of 10% or under.
Five regions in Ontario had rates above
the overall average.
About Our Results
This study uses data from CIHI’s Hospital Morbidity Database. To make mortality rates as comparable as possible, we used
these data to develop risk-adjusted regional mortality rates over a three-year period. Rates and confidence intervals for regions
with a population of 100,000 or more are included in Health Indicators 2002, an insert to this report. Detailed descriptions of
our methods and technical notes are available on the CIHI web site (www.cihi.ca).
Cumulative percentage
Understanding the results:
• Our analysis is based on where patients live, not where they are treated. As a result, the rates reflect mortality for AMI or
stroke patients resident in a region (who may also receive care elsewhere), rather than the outcomes of care for hospitals in
the region (who may also treat patients from other areas).
• We included only patients who had a new AMI or stroke, leaving out anyone who had already been hospitalized with the
condition in the past year. We included both ischemic (interruption of blood flow to the brain) and hemorrhagic (the rupture
of blood vessels in the brain) stroke, in the analysis, as well as those reported as “ill-defined”. This decision, along with
other aspects of the stroke indicator, was reviewed with experts from the Canadian Stroke Network.
• We counted deaths within 30 days in any hospital, not just those in the first hospital where a patient was treated. We could
not include patients who died before reaching a hospital.
• We used well-tested methods to adjust for differences in age, sex, and co-morbidity across regions. Nevertheless, we could
only use data available to us. Consequently, differences
35
across regions may reflect variations in risk factors, in care Deaths In and Out of Hospital for AMI
Cumulative rate of death up to 30 days after initial
before admission and after discharge, or in hospital
hospitalization with AMI, three provinces, 1995/96.
documentation practices that we were not able to take
account of, not just the quality of care patients received in
25
hospital.
20
• This study compares 30-day in-hospital mortality rates, a
commonly used outcome measure in research studies on
15
both AMI and stroke. For these patients, there is a strong,
10
but not perfect, relationship between deaths in hospital
and out of hospital over this period. For example,
5
Statistics Canada found that about 95% of all deaths
0
within 30 days of initial hospitalization for AMI in
0
4
8
12
16
20
24
28
1995/1996 in three provinces occurred in a hospital. The
days after admission to hospital
majority of deaths within one year after an AMI occur
within the first 30 days.
all deaths
deaths in hospital
• We report 95% confidence intervals for all mortality rates.
Source: Person-Oriented Information Project, Statistics Canada
These intervals tend to be larger (i.e. the rate estimate is
less precise) for regions that treat fewer patients. For
example, Toronto’s AMI rate is estimated to be accurate to within ± 0.52 percentage points 19 times out of 20. In contrast,
Lakeland, Alberta’s (with only a fraction of Toronto’s cases) is within ± 2.83 percentage points. As a result, we based the
rates that we report here on data pooled over a three-year period (1997/1998 to 1999/2000).
* Rates for British Columbia, Quebec, and Newfoundland are not available
due to differences in how hospital data are collected.
43
HEALTH CARE IN CANADA 2002
The stroke findings are similar to those
for AMI. Overall, 19.2% of stroke patients
died in a hospital within 30 days of initial
hospitalization between 1997/1998 and
1999/2000.‡ In most cases, rates for large
health regions (with a population of
100,000 or more) were similar to this
overall average. But, 12 of 36 regions
had rates that were statistically
significantly different from it: six were
higher and six were lower. Across all
regions included, mortality rates ranged
from 15% to 35%.
Why do mortality rates for some regions
differ from the overall average? Some of
the variation may be due to risk factors or
conditions that we were not able to
adjust for. For example, specialized care
Regional Variations in Mortality Following a Stroke
36
Across the country, 19.2% of patients died in hospital within 30 days of initial hospitalization for a stroke
between 1997/1998 and1999/2000. As for heart attacks, many regions had rates that were about the
same as this overall rate. But others have higher or lower rates even after adjusting for age, sex, and other
co-existing illness. Available data over this three-year period for regions with a population of 100,000 or
more are shown below. The rates (shown by circles) are estimated to be accurate to within the range
indicated by the vertical bars 19 times out of 20 (95% confidence interval). The solid line represents the
overall average of 19.2%.
45
40
Risk-adjusted 30 Day In-Hospital Mortality Rate (%)
35
30
25
20
15
10
5
PE
Lakeland Regional Health Authority, AB
Saskatoon Service Area, SK
Capital Health Authority, AB
Calgary Regional Health Authority, AB
Grey-Bruce-Huron and Perth DHC, ON
Waterloo-Wellington-Dufferin DHC, ON
Simcoe-York DHC, ON
Halton-Peel District Health Council, ON
Northwestern Ontario DHC, ON
Durham-Haliburton-Kawartha and Pine Ridge DHC, ON
Regina Service Area, SK
Toronto District Health Council, ON
Essex-Kent and Lambton DHC, ON
David Thompson Regional Health Authority, AB
Hamilton-Wentworth DHC, ON
East Central Health Authority, AB
Winnipeg, MB
Champlain District Health Council, ON
Saint John Area, NB
Quinte-Kingston and Rideau DHC, ON
Chinook Regional Health Authority, AB
Thames Valley DHC, ON
Niagara District Health Council, ON
Health and Community Services St.John’s Region, NF
Zone 5, NS
Algoma-Cochrane-Manitoulin and Sudbury DHC, ON
Grand River DHC, ON
Zone 6, NS
Moncton Area, NB
Fredericton Area, NB
Muskoka, Nipissing, Parry Sound and Timiskaming DHC, ON
Zone 1, NS
Health and Community Services Central Region, NF
Zone 3, NS
Health and Community Services Eastern Region, NF
0
Note: Data from British Columbia and Quebec are excluded due to differences in how hospital data are collected.
Source: Hospital Morbidity Database, CIHI
Data for Quebec and British Columbia were not available due to differences
in how hospital data are collected.
‡
44
i
4. OUTCOMES OF CARE
following stroke has been related to
survival.7,8,9 However, Ontario researchers
note that people living in poorer
neighbourhoods have less access to some
of these services and are more likely to die
following a stroke than those living in
wealthier neighbourhoods.7 Other factors
may also play a role, including disease
severity, lifestyle choices, and medication
compliance.8,9 Not all of these factors are
well documented in patient records. And,
still others may exist that are not well
understood today. As a result, these data
are an important step, but just a first step,
in an on-going process to better
understand outcomes of care and the
factors that contribute to them.
Returning to Hospital
Most patients recover at home or in other
types of facilities once discharged from the
hospital. However, some must return to
hospital within a short period because they
experience further health problems or need
additional care.10
The quality of care a patient receives while
hospitalized can influence readmission
rates. So too, can a variety of other factors,
such as how sick they are, their ability or
willingness to undertake post-hospital
treatment, the level of follow-up care
available in their community, and much
more. Not all readmissions are avoidable or
preventable, but high rates can trigger
further exploration and analysis.11
i
What is a readmission and how are readmission rates calculated?
This study uses data from CIHI’s Hospital Morbidity and Discharge Abstract Databases. It builds on methods originally developed by
researchers at the University of Toronto to calculate quality-related readmission rates in Ontario for selected inpatient procedures
including AMI and asthma.17 We adapted these methods, designed to calculate rates at a hospital level, to produce readmission rates for
large regions across Canada.
Understanding the results:
• As far as possible, we only counted unplanned readmissions due to a related health problem within 28 days after the first or index
admission. A return to hospital for planned surgery (e.g. revascularization or pacemaker procedures following an AMI admission)
would not be counted. Similarly, when a patient was readmitted for a condition clearly not attributable to the initial diagnosis, we did
not count it as a readmission. Patients admitted with conditions of cancer or HIV were also excluded. So were patients who signed
themselves out of hospital or died during their initial hospital stay. These decisions were based on the advice of clinical panels.
• Our analysis is based on where patients live, not where they are treated. As a result, rates reflect readmissions for patients resident in a
region (who may also receive care elsewhere), rather than the outcomes of care for hospitals in the region (who may also treat patients
from other areas).
• To avoid multiple counting, patients transferred from one acute care hospital to another within 12 hours of discharge from the first
hospital, were generally considered to have had a single admission (i.e. a transfer, not a readmission). If more than one true
readmission occurred within the 28-day period, we included only the earliest one in the analysis.
• We used well-tested methods to adjust for differences in age, sex, and co-morbidity across regions. Nevertheless, we could only use data
available to us. Consequently, differences across regions may reflect variations in risk factors, in care before admission and after
discharge, or in hospital documentation practices that we were not able to take account of, not just the quality of care patients received
in hospital.
• Ninety-five percent confidence intervals were calculated for all readmission rates. The confidence limits tend to be larger (i.e. the rate
estimate is less precise) for regions with fewer patients in a given year. For example, Toronto’s readmission rate for AMI is estimated to
be accurate to within ±0.53 percentage points 19 times out of 20. In contrast, the rate for AMI readmission in East Central Health
Authority in Alberta (with only a fraction of Toronto’s cases) is within ± 2.57 percentage points. As a result, we based the rates that we
report here on data pooled over a three-year period (1997/1998 to 1999/2000).
Rates and confidence intervals for regions with a population of 100,000 or more are included in Health Indicators 2002, an insert to
this report. Detailed descriptions of our methods and technical notes are available on the CIHI web site (www.cihi.ca).
45
HEALTH CARE IN CANADA 2002
Readmissions for AMI
and Asthma
Regional Variations in Heart Attack Readmissions
37
The chances of a patient being readmitted to hospital within 28 days of initial hospitalization for heart
attack (adjusted for age, sex, and other co-existing illness) varied from region to region between
1997/1998 and 1999/2000. Available data for over this three year period for regions with a population
of 100,000 or more are shown below. The rates (shown by circles) are estimated to be accurate to within
the range shown by the bars 19 times out of 20 (95% confidence interval). The solid line represents the
overall average of 7.3%. Regions where data were unavailable or where a valid risk-adjusted rate could
not be estimated with the existing data have been omitted.
17
16
15
14
Risk-adjusted 28 day Hospital Readmission Rate (%)
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Upper Island/Central Coast, BC
Central Vancouver Island, BC
Muskoka, Nipissing, Parry Sound and Timiskaming DHC, ON
Northern Interior, BC
Thompson, BC
PE
Grand River DHC, ON
Zone 3, NS
Zone 5, NS
Fredericton Area, NB
Quinte-Kingston and Rideau DHC, ON
Durham-Haliburton-Kawartha and Pine Ridge DHC, ON
Essex-Kent and Lambton DHC, ON
Zone 1, NS
Waterloo-Wellington-Dufferin DHC, ON
David Thompson Regional Health Authority, AB
Algoma-Cochrane-Manitoulin and Sudbury DHC, ON
Northwestern Ontario DHC, ON
Simcoe-York DHC, ON
East Central Health Authority, AB
Grey-Bruce-Huron and Perth DHC, ON
Niagara DHC, ON
South Fraser Valley, BC
Lakeland Regional Health Authority, AB
Moncton Area, NB
Chinook Regional Health Authority, AB
Fraser Valley, BC
Champlain DHC, ON
Saskatoon Service Area, SK
Okanagan Similkameen, BC
Thames Valley DHC, ON
Hamilton-Wentworth DHC, ON
Toronto DHC, ON
North Okanagan, BC
Halton-Peel DHC, ON
Regina Service Area, SK
North Shore, BC
Saint John Area, NB
Vancouver/Richmond, BC
Capital (Victoria), BC
Calgary Regional Health Authority, AB
Simon Fraser (includes Burnaby), BC
Zone 6, NS
Capital Health Authority, AB
i
In Canada and elsewhere, many
researchers have studied hospital
readmission rates.10,11,12,13,14,15,16 This year, for
the first time, we report on hospital
readmission rates for AMI, asthma,
hysterectomy, and prostatectomy at the
regional level across much of the country.§
Across all regions (large and small),
7.3% of AMI patients had an unplanned
return to hospital within 28 days due to a
related health problem. For asthma, the
rate was 6.4%. Many regions were similar
to the overall rates, but some were
significantly different, even after adjusting
for differences in risk factors. For example,
seven health regions had readmit rates for
AMI of under 5%, and seven regions had
rates that were more than twice as high.
Readmission rates for asthma also
showed some regional variations. Ten
regions—five in British Columbia, two in
Alberta, and one each in Saskatchewan,
Note: Data from Manitoba, Newfoundland, and Quebec are excluded due to differences in how hospital data are collected.
Source: Discharge Abstract Database, CIHI
§
Results for Newfoundland (AMI only), Manitoba, and Quebec were not
available due to differences in how hospital data are collected.
46
4. OUTCOMES OF CARE
Ontario, and Nova Scotia—had rates that
were substantially higher than the overall
average. Five regions—four in Ontario and
one in Alberta—had rates that were
substantially lower than the overall average.
Why do readmission rates vary from
region to region? Rates can be affected by
a number of factors. Some are related to
care during the initial hospital stay, but
many are not. For example, the chances of
readmission after hospitalization for an AMI
may be affected by patient characteristics,
the availability of appropriate diagnostic
and other technology during the initial
hospital stay, follow-up care after
discharge, and many other factors.
As for the 30-day in-hospital mortality
indicators, many of these additional factors
are not well documented in patient records
nation-wide. Likewise, additional reasons
for variations may also exist, even if they
are not well understood today. Once again,
in understanding how hospital care affects
short- and long-term health outcomes,
these measures should be considered in the
context of other information, such as patient
characteristics, patient care, and health
services in and out of hospital.
Regional Variations in Asthma Readmissions
38
The chances of a patient being readmitted to hospital within 28 days of initial hospitalization for asthma
(adjusted for age, sex, and other co-existing illness) varied from region to region between 1997/1998
and 1999/2000. Available data over this three-year period for regions with a population of 100,000 or
more are shown below. The rates (shown by circles) are estimated to be accurate to within the range
shown by the bars 19 times out of 20 (95% confidence interval). The solid line represents the overall
average of 6.4%. Regions where data were unavailable or where a valid risk-adjusted rate could not be
estimated with the existing data have been omitted.
16
Risk-adjusted 28 Day Hospital Readmission Rate (%)
14
12
10
8
6
4
0
Lakeland Regional Health Authority, AB
Vancouver/Richmond, BC
North Okanagan, BC
Saskatoon Service Area, SK
South Fraser Valley, BC
David Thompson Regional Health Authority, AB
Okanagan Similkameen, BC
Grand River DHC, ON
Zone 6, NS
Fraser Valley, BC
East Central Health Authority, AB
Niagara DHC, ON
Northern Interior, BC
Zone 1, NS
Durham-Haliburton-Kawartha and Pine Ridge DHC, ON
Northwestern Ontario DHC, ON
Moncton Area, NB
PE
Central Vancouver Island, BC
Grey-Bruce-Huron and Perth DHC, ON
Champlain DHC, ON
Simon Fraser (includes Burnaby), BC
Halton-Peel DHC, ON
Toronto DHC, ON
Algoma-Cochrane-Manitoulin and Sudbury DHC, ON
Waterloo-Wellington-Dufferin DHC, ON
Regina Service Area, SK
Thames Valley DHC, ON
Fredericton Area, NB
Calgary Regional Health Authority, AB
Simcoe-York DHC, ON
Capital (Victoria), BC
Thompson, BC
Saint John Area, NB
Muskoka, Nipissing, Parry Sound and Timiskaming DHC, ON
Health and Community Services Eastern Region, NF
Essex-Kent and Lambton DHC, ON
Quinte-Kingston and Rideau DHC, ON
Capital Health Authority, AB
Zone 5, NS
Upper Island/Central Coast, BC
Health and Community Services St.John’s Region, NF
North Shore, BC
Hamilton-Wentworth DHC, ON
2
Note: Data from Manitoba and Quebec are excluded due to differences in how hospital data are collected.
Source: Discharge Abstract Database, CIHI
47
HEALTH CARE IN CANADA 2002
Survival After A
Cancer Diagnosis
Cancer is the leading cause of premature
death in Canada. It is responsible for about
one-third of all potential years of life lost.18
The National Cancer Institute of Canada
estimates that there were 134,000 new
cancer cases and 65,300 deaths
attributable to cancer in 2001.
How does a cancer patient’s risk of dying
compare to that of the general population?
To find out, Statistics Canada calculated
five-year “relative” survival rates for patients
diagnosed with primary breast, colorectal,
lung, or prostate cancers in 1992.
breast cancer (85%) was highest in British
Columbia. This compares to national rates
of 87% and 82% respectively. For colorectal
cancer patients, relative survival was lowest
for men in New Brunswick (47%), compared
to 56% for all men, nationally. In general,
lung cancer patients continue to have the
worst survival prospects. National five-year
relative survival rates were 14% for men and
17% for women.
Surviving Breast Cancer
39
A woman between the ages of 15 and 99 diagnosed with
breast cancer in 1992 had a five-year relative survival rate of
over 80%, but inter-provincial variations exist. British Columbia
had the highest five-year relative survival rate at 85%.
NF
What is a Relative Survival Rate?
Relative survival rates for cancer measure how much more likely it is
that someone diagnosed with cancer will die within a specified time
period compared to a similar person in the general population. For
example, consider two hypothetical groups of ten people. The first is
newly diagnosed with some type of cancer. The second with similar age,
sex, and province of residence characteristics is chosen at random from
the general population. Five years later, five of the first group and seven
of the second are still alive. The ratio of the survival in the first group to
that of the second group is the relative survival. In this example, those
diagnosed with this cancer were 71% (5/7) as likely to survive five years
as were those from the general population.
Diagnosed with Cancer
survival = 50%
General Population
NS
NB
ON
MB
SK
AB
BC
CAN
0
20
40
60
5-year relative survival (%)
80
Note: Rates are age-standardized to the 1992 Canadian case distribution of the cancer site
under study. Results for Prince Edward Island, the Yukon, and the Northwest Territories are not
shown because of an insufficient number of cases. The national rate excludes Quebec due to
its difference in cancer reporting methodology but does include Prince Edward Island, the
Yukon, and the Northwest Territories.
* significantly different (p < .05) from the national breast cancer relative survival rate of 82%.
Source: Canadian Cancer Registry, Statistics Canada
survival = 70%
Relative Survival = 50%/70% = 71%
= survived at least 5 years
= deceased within 5 years
Note: Numbers are for illustrative purposes only. They do not represent actual survival rates.
They found that relative survival rates
sometimes depend on where you live. For
example, five-year relative survival for
people diagnosed with prostate (91%) or
48
In general, longer survival times could
mean one of two things. It could be that
cancer is being diagnosed at an earlier
stage (possibly because of effective
screening programs). Or, it could mean that
patients with cancer are living longer,
perhaps due to better treatment. With
improved tracking of tumor stage in the
future, it should be possible to disentangle
these and other effects.
4. OUTCOMES OF CARE
Childhood Cancer
For Canada’s children, a diagnosis of cancer isn’t the death
sentence it once was.18 Over the last 30 years, survival chances
have improved substantially. Five-year survival rates are now
about 75%.19 That’s good news for the 1,266 children each year
who were diagnosed with cancer, on average, between 1992 and
1996, according to the National Cancer Institute of Canada. The
bad news is that an average of 249 children still died of cancer
each year. The most common childhood cancer is leukemia. It
accounts for 26% of new cases and 32% of deaths. Other
common types include brain and spinal cord cancer (17% of new
cases) and lymphoma (16% of new cases).18
Across Canada, 27 hospitals performed
a total of 1,820 single organ transplants in
2000. Most (61%) were for kidneys,
followed by livers (22%), hearts (9%), and
lungs (almost 7%).
Increasing Transplant Activity
70
When One
Organ Fails…
60
50
Rate Per Million Population
It’s almost 70 years since the first
human-to-human kidney transplant
operation was performed in 1933.
Unfortunately, the kidney never functioned.
It took another 20 years before Boston
surgeons performed the first successful
kidney transplant operation.20 Today,
kidney transplants, as well as the
transplantation of other organs, are
increasingly common.
40
The graph below illustrates the number of transplants per
million population by organ type. Kidney transplants are by far
the most common type of solid organ transplants. Rates of
kidney and other transplants have generally increased over
time, as the graph below shows.
40
30
20
10
All*
Kidney
Liver
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
Islet Cell Transplantation
In people with Type I diabetes, islet cells are destroyed by the
body’s immune system. These cells produce insulin, which helps
the body use glucose for energy. Pancreatic islet cell
transplantation has been considered as a possible long-term
treatment option. In pancreatic islet transplantation, cells are
taken from the donor pancreas and transplanted into the
recipient. The hope is that the transplanted cells start producing
insulin for the new host. In 1989, researchers at the University of
Alberta performed the first Canadian islet cell transplant. The
operation wasn’t successful in the long-term. In 1999, the same
researchers developed a new transplantation procedure with
these cells. The procedure became known as the “Edmonton
Protocol”. So far results seem promising. But further research is
required to establish long-term outcomes. 21,22
1981
0
Heart
Note: “All” also includes pancreas, heart-lung, single lung, double lung, and bowel transplants.
Source: Canadian Organ Replacement Register, CIHI
Nevertheless, the number of patients
waiting for organ transplants is climbing.
As of September 30, 2001, 3,901 patients
were waiting for a solid organ transplant in
Canada. That’s up 51% from 1995. About
three-quarters (77%) of those on the 2001
waiting list needed a kidney transplant.
Another 11% were waiting for a liver.
Heart, single and double lung, and
kidney/pancreas patients accounted for
less than 5% each.
49
HEALTH CARE IN CANADA 2002
The Waiting Game
41
As of September 30, 2001, there were 3,901 patients waiting
for a solid organ transplant in Canada, up 51% from 1995. In
2001, almost 77% of patients on the waiting list were waiting
for kidneys, followed by patients waiting for livers (11%), and
hearts (3%).
1995
1996
1997
1998
1999
2000
2001
0
1000
2000
3000
4000
# of patients waiting for solid organ transplant
Kidney
Liver
Pancreas
Kidney-pancreas
Heart
Heart-lung
Single and double lung
Other/combination
5000
Notes: As of 1997, waiting lists include patients who are “on hold” (patients who cannot
receive a transplant for a medical or other reason for a short period of time) as well as active
patients who can receive a transplant any time.
The kidney waiting list for British Columbia has been frozen for everyone except priorities (i.e.
pediatrics, multi-organ transplants, and medical priorities) since October 2000. As a result,
there has been a decrease in the reported number of patients waiting for kidney transplants
between 2000 and 2001 in that province.
Organ supply is not keeping pace with
this rising demand. Cadaveric donor rates
have been relatively stable over the past
five years. The current rate is
approximately 14 per million population.
In contrast, living donor rates have more
than doubled since 1992. In 2000,
Canada’s live donor rate was 13.3 per
million population.
Both cadaveric and living donor rates
vary across the country. Between 1998 and
2000, Alberta, Saskatchewan, and Quebec
had the highest cadaveric donor rates.
Why do provincial donor rates vary? It’s
possible that population characteristics,
hospital resources, cultural differences, and
other factors (some of which may not yet
have been identified) play a role.23
Leaving a Legacy
42
Between 1998 and 2000, the average cadaveric organ donor
rate in Canada was 14.3 per million population. Alberta
(17.6), Saskatchewan (17.5), and Quebec (17.5) had donor
rates above the national average. British Columbia had the
lowest rate, at 9.6 donors per million population.
20
Source: Canadian Organ Replacement Register, CIHI
18
Living vs. Deceased Donors—
Is there a Difference?
An organ transplant can either come from a cadaveric donor or a
living donor. What’s the difference? A cadaveric organ donor is a
donor who is declared brain dead and has consented to the donation
of an organ(s). A living organ donor, on the other hand, is alive.
They usually have a biological (related) and/or emotional
relationship (unrelated) to the transplant recipient. Living donors
most commonly donate one of their kidneys. However, a living donor
may also donate a lung or part of a liver, lung, or pancreas.
Patients who receive organs from living donors tend to have better
survival outcomes than those who receive cadaveric organs.23,24
Possible explanations include better tissue matching between the
living donor and recipient, improvements in the use of
immunosuppressive drug therapy, shorter waiting times for patients,
improved white blood cell antigen matching, and greater oxygen
content in the living donor organ tissue.24,25
50
Rate per million population
16
14
12
10
8
6
4
2
0
ATL
QC
ON
MB
SK
AB
BC
CAN
Note: The three-year average for the regions above are not adjusted for factors which may affect
organ donor rates, such as population characteristics, hospital resources, or cultural differences.
Source: Canadian Organ Replacement Register, CIHI
4. OUTCOMES OF CARE
Another way to measure cadaveric
donation rates is to calculate the
proportion of potential donors who actually
donate organs for transplant. This measure
is more complicated because it requires an
estimate of the number of “potential”
donors. CIHI recently released a discussion
paper which explored administrative
methods to measure potential donors.
Depending on the method used, between
1992 and 1998, approximately four to
fifteen out of every 100 potential cadaveric
organ donors ended up being organ
donors. These methods take into account
potential differences among the provinces
in age, sex, mortality, and other factors.26
Xenotransplantation—Should
Canada Proceed?
Growing waiting lists for transplants have meant that
scientists are searching for alternatives. Xenotransplantation—
transplanting animal cells, tissues, or organs into humans—is
one controversial possibility.
Governments recently asked the Canadian Public Health
Association to convene an advisory group to develop
recommendations on animal-to-human transplants. As part of
this process, they consulted with the general public in two ways:
a telephone survey and a two-day citizen forum. The feedback
that they received differed. For example, 65% of respondents
to the telephone survey said that Canada should go ahead with
xenotransplantation. In contrast, only 46% of those attending
the citizen forum, which included receiving extensive
background information on the topic, agreed.
Issues raised during the consultation process included:
• Concerns about health risks and the number of unsuccessful
attempts to date;
• A desire to find a means of addressing the current organ
shortage in Canada; and
• The need for strict and clear legislation and regulation of
research practices with clinical trials before
xenotransplantation is undertaken.
At the end of the day, the Advisory Group concluded that
Canada should not proceed with xenotransplantation until these
issues could be resolved.
†
After a Transplant…Survival
In Canada, the chances of surviving one,
three, or five years following an organ
transplant have been increasing. People
receiving kidney or heart transplants
between 1995 and 2000 had better
survival chances than those who received
transplants between 1989 and 1994.
For kidney transplants, survival chances
were about the same in all regions of the
country where data were available between
1995 and 2000. That’s true at the one-,
three-, and five-year marks.
Survival Five Years Later
43
Five-year survival estimates for Canadians receiving a kidney
or heart transplant between 1995 and 2000 were higher
than for patients transplanted between 1989 and 1994. The
table below shows the survival estimates and their 95%
confidence intervals.
Source: Canadian Organ Replacement Register, CIHI
There were, however, pockets of
differences for those having heart and liver
transplants. For example, three-year
survival for heart transplant patients was
higher in the West (85.4%) than in Quebec
(72.7%).† For liver transplants, the
probability of surviving three years was
higher in Ontario (88.0%) than in Quebec
(71.0%) and the Western provinces
(78.9%). A number of possible
explanations for these differences exist,
including unidentified variations in risk
factors, such as patient comorbidity (e.g.
other co-existing illnesses, such as diabetes
or hypertension).
Statistically significantly different (p=0.05).
51
HEALTH CARE IN CANADA 2002
Regional Survival Differences
44
Patients who received cadaveric kidney transplants in Quebec,
Ontario, and the western provinces between 1995 and 2000
had relatively similar outcomes. In contrast, some regional
variations in unadjusted survival rates were noted for heart and
liver transplants. This may be due to differences in actual
survival chances, in comorbid conditions, in the extent and
accuracy of reporting between regions, or in other factors.
International Comparisons
in Survival Rates
45
Survival rates five years after a kidney transplant were higher for
Canadian patients in each of the age groups shown below than
for their American counterparts. In contrast, Canadians aged
35 to 49 had worse outcomes for liver transplantation. Data
are for patients who received transplants between January 1990
and December 1998. Ninety-five percent confidence intervals
are shown in brackets below the survival estimates.
Quebec
Ontario
Source: Canadian Organ Replacement Register, CIHI;
2000 Annual Report, UNOS Scientific Registry Data (US).
West
0
20
40
60
% alive after 3 years
Kidney
Heart
80
100
Liver
Note: Data from the Atlantic provinces are suppressed.
Source: Canadian Organ Replacement Register, CIHI
On the International Front
Comparisons within Canada are often
hard. Comparing transplant survival
between countries is even more difficult.
How countries count and distribute their
resources often varies and can affect
research results. So can differences in
patient characteristics and other factors.
Bearing this in mind, cautious comparisons
are possible. According to recent data
(January 1990 to December 1998),
Canadians have better chances of
surviving a kidney transplant than do
Americans.
52
Volume and Surgical
Outcomes—Another
Look
All surgery carries risks. The goal is to
minimize risks, with a view to bettering
long-term health, well being, and life
expectancy. This is the balancing act that
thousands of Canadians who have surgery
each year face.
When you need surgery, many factors can
affect where you get the operation. If you
need emergency surgery, there may be little
choice. But when a procedure is planned in
advance, recommendations from physicians,
family, or friends may affect where you seek
care. Location, availability, and convenience
might also be decisive. And many other
factors may enter into the decision.
In last year’s report, we noted that the
number of both rare and common surgical
procedures currently performed by individual
hospitals in Canada varies, often
significantly. At the same time, for many
types of care and for many different
surgeries, research shows that patients
treated in hospitals with higher numbers of
cases are often less likely to have
complications or to die after surgery.28
4. OUTCOMES OF CARE
Many of the studies are from other
countries, but Canadian researchers have
studied some types of care in detail.29,30
Volume-outcome relationships are also
clearly an area of current Canadian
clinical and policy interest. Indeed, the
recent Sinclair inquest found that “the
limited number of cases [of pediatric
cardiac surgery] that can be undertaken in
a province like Manitoba with a population
of just over one million increases the risk of
morbidity and mortality.”31 And Canada’s
first ministers recently committed to sharing
human resources and equipment in order
to develop sites of excellence that will
specialize in low-volume procedures such
as pediatric cardiac surgery and gamma
knife neurosurgery.32
The Situation in Canada:
New for This Year
This year, we expanded our analysis of
surgical volumes to a broader range of
procedures. Some, such as hysterectomy
(removal of the womb) and cholecystectomy
(removal of the gall bladder), are already
common. Others are less frequent but rates
Surgery in Canada: Who Does What
and How Many
46
Every year, surgeons perform hundreds of thousands of
procedures in hospitals across the country. Some are common.
Others are rare. To illustrate the range, the table below
summarizes how selected procedures are delivered, how many
procedures were performed in 1999/2000, and how these
numbers have changed over time.
Notes:
* Spec=specialized setting, non-spec=non-specialized setting
**Excludes Quebec, Manitoba, and Alberta due to differences in how hospial data are reported.
Source: Hospital Morbidity Database and Discharge Abstract Database, CIHI
are increasing (e.g. hip and knee
replacements). We also included one
example of a rare operation: the Whipple
procedure (surgery for pancreatic cancer).
In 2000, Dudley and colleagues28
summarized the findings of a large number
of research studies on volume-outcome
relationships. Their systematic review of the
literature included the five procedures
mentioned above. They found two studies for
hysterectomy, four for cholecystectomy, nine
for hip replacement, three for knee
replacement, and eight for pancreatic cancer
surgery. All studies showed better outcomes
with higher volumes. In most, but not all,
cases results were statistically significant.
Since then, several new studies have
appeared. For example, the April 11, 2002
issue of the New England Journal of
Medicine33 carried an article on the
relationship between hospital volume and
mortality in the United States. Journal editors
said that it might be the largest such study
conducted to date.34 In future systematic
reviews, its findings can be integrated with
those of previous studies.
Researchers examined the outcomes of
Medicare patients (aged 65 to 99) who
received one of 14 types of cardiovascular
and cancer procedures. The study included
2.5 million surgeries performed between
1994 and 1999. For all types of procedures
studied, researchers found that higher
volume hospitals tended to have lower riskadjusted mortality rates. But the strength of
this relationship varied from procedure to
procedure. The absolute difference in riskadjusted mortality rates between the lowest
and highest volume hospitals ranged from
0.2% to over 12%.
While it seems clear for at least some
procedures that volume-outcome
relationships exist, what isn’t entirely clear is
why. Some have suggested that, simply put,
practice makes perfect. That is, hospitals that
have higher volumes develop better skills.35,36
53
HEALTH CARE IN CANADA 2002
Another possible explanation is that more
people go to hospitals that have better
outcomes. That is, superior performance
attracts more patients over time. This is
known as the “selective referral” theory.35,37
Another outstanding question is the exact
nature of the relationship between volumes
and outcomes. For example, is there a
“threshold” number of cases—a specific
volume for a particular procedure—
associated with better outcomes? Or do
outcomes get steadily better with higher case
volumes? For the most part we don’t know.
Volumes of Knee Replacements
Across Canada
48
The degree of centralization of knee replacement surgery varies
across the country. The graph below shows the percent of
surgeries performed in hospitals caring for fewer than 50, 5074, 75-99 or 100 or more cases in 1999/2000. The number
in parentheses is the age-standardized rate of knee
replacements per 100,000 residents in 1999/2000. For
example, residents of Nova Scotia and Manitoba were the
most likely to have knee replacement surgery.
NF (36)
NS (99)
NB (76)
What the Data Show
QC (34)
Most Canadians receive surgery in high
volume hospitals, but many hospitals
perform a very small number of procedures.
For example, while over seven in 10 of the
knee replacements done in 1999/2000
were performed in hospitals doing over
100 cases are year, almost seven percent
ON (78)
MB (95)
SK (71)
AB (76)
BC (65)
CAN (66)
Volumes of Hip Replacements
Across Canada
47
The degree of centralization of hip replacement surgery varies
across the country. The graph below shows the percent of
surgeries performed in hospitals caring for fewer than 50,
50-74, 75-99, or 100 or more cases in 1999/2000. The
number in parentheses is the age-standardized rate of hip
replacements per 100,000 residents in 1999/2000. For
example, residents of Nova Scotia, Manitoba, and Alberta
were the most likely to have hip replacement surgery.
NF (36)
NS (76)
NB (61)
QC (36)
ON (67)
MB (74)
SK (71)
AB (75)
BC (64)
CAN (60)
0%
20%
Less than 50 cases
40%
60%
80%
Surgeries performed by hospital volume group
50-74 cases
75-99 cases
100%
100 or more cases
Note: Data for PEI were suppressed due to confidentiality considerations.
Source: Hospital Morbidity Database, CIHI
54
0%
20%
Less than 50 cases
40%
60%
80%
Surgeries performed by hospital volume group
50-74 cases
75-99 cases
100%
100 or more cases
Note: Data for PEI were suppressed due to confidentiality considerations.
Source: Hospital Morbidity Database, CIHI
(or 1,474) were done in hospitals doing less
than 50 cases a year.
In addition, the degree to which care is
concentrated in a few high-volume centres
isn’t necessarily related to the total number
of procedures performed. For example, in
Quebec, almost 30% of the 2,700 knee
replacements and 2,900 hip replacements
in 1999 took place in hospitals that did
fewer than 50 procedures per year.
Whereas in Manitoba and Nova Scotia—
two provinces with less than half the volume
of cases as in Quebec—under 8% in
1999/2000 were performed in hospitals
with fewer than 50 cases.
4. OUTCOMES OF CARE
Volumes of Pancreatic Cancer Surgery
Across Canada
49
The degree of centralization of pancreatic cancer surgery,
also known as Whipple procedure, varies across the country.
The graph below shows the percent of Whipple procedures
performed in hospitals caring for fewer than 5, 5-6, 7-9, 1025, or 25-49 cases in 1999/2000. The number in parentheses
is the age-standardized rate of Whipple surgeries per 100,000
residents in 1999/2000. This type of surgery is very rare.
ATL (3.0)
QC (2.0)
ON (1.7)
MB (1.8)
SK (1.2)
AB (1.9)
BC (1.5)
CAN (1.9)
0%
20%
Less than 5 cases
40%
60%
80%
Surgeries performed by hospital volume group
5-6 cases
7-9 cases
10-24 cases
100%
25-49 cases
To support the discussion, we have again
included rates of several types of surgery
and patient inflow/outflow indicators in
Health Indicators 2002. The latter show
variations in the extent to which patients
travel from region to region to seek care. A
high score on this measure suggests a
larger degree of centralization with many
patients coming in from outside the region
for care. Specialized procedures, such as
coronary artery bypass surgery, tend to be
more centralized than more common types
of operations, such as gall bladder
removal or hysterectomies.
In this context, systematic reviews of the
research literature, an understanding of
current Canadian volume patterns, and
better information about patient outcomes
at individual hospitals could all provide
evidence to support decisions about how
best to organize health services and
distribute health care resources.
Note: Data for the Atlantic provinces were grouped due to confidentiality considerations.
Source: Hospital Morbidity Database, CIHI
Trade-Offs to be Made?
Concentrating surgical procedures in
centres that perform a large number of
cases—sometimes referred to as
regionalization or centralization—may lead
to significant benefits. These include
developing specialized expertise in health
care teams, optimal use of costly
equipment, and achieving better outcomes
for patients.
On the other hand, many argue that
centralizing care could have adverse effects,
especially in rural areas. For example, it
might create travel burdens, interfere with
continuity of care, and ultimately decrease
access to necessary care for patients living
far from referral centres.
As we said last year, deciding how much
to centralize care requires us to strike a
balance across these issues. This balance is
likely to vary from procedure to procedure
and place to place.
55
i
HEALTH CARE IN CANADA 2002
Information Gaps—Some Examples
What We Know
• How death rates (adjusted for age, sex, and comorbidities) in the first 30 days after
initial hospitalization with an AMI or stroke compare across the country.
• How readmission rates (adjusted for age, sex, and comorbidities) in the first 28 days
after initial hospitalization for AMI, asthma, hysterectomy, and prostatectomy
compare across the country.
• How five-year age-standardized relative survival rates for breast, prostate, colorectal,
and lung cancer compare provincially.
• Transplant and organ donor statistics, as well as long-term survival for kidney, liver,
and heart transplant patients.
• For different types of surgery, how many surgical cases take place in high- and lowvolume settings.
What We Don’t Know
• What explains regional differences in mortality, readmissions, and survival?
• For which, if any, surgeries do hospitals performing low numbers of operations place
patients at higher risk of complications and death? For these procedures, what is the
optimal or minimum number of cases a hospital should perform to provide safe and
effective care? How many deaths could potentially be prevented by ensuring that
surgery is provided at high-volume centres? What would be the other trade-offs if
surgical procedures were centralized?
• What is the relationship between how much we spend on particular interventions and
the benefits they provide?
• How healthy are patients three, six, and 12 months after most types of surgery?
What’s Happening
• Health Canada and the Canadian Standards Association are working together on
the development and publication of national standards to improve organ and tissue
donation practices in Canada. The standards are expected to be completed in 2003.
• Canada’s premiers and the prime minister agreed to track and report on longer-term
survival following AMI and stroke, where possible, by September 2002.
• Researchers at the University of Alberta are continuing to investigate the long-term
outcomes of islet cell transplants in people who have Type I diabetes. As of October
2001, 12 of 15 transplant patients participating remain insulin free. Vancouver
Hospital has also embarked on a research study to examine the potential benefits of
islet cell transplantation for Type I diabetes.
• Following the first ministers’ January 2002 meeting in Vancouver, health ministers
were directed to develop an action plan to implement sites of excellence for lowvolume procedures, such as pediatric cardiac surgery and gamma knife
neurosurgery. The action plan is set to be tabled at the first ministers’ meeting in
August, 2002.
• CIHI and the Canadian Institutes for Health Research are co-sponsoring research to
estimate the extent of adverse events in Canadian hospitals and the availability of
data that could be used to support continuous monitoring and reduce these events.
56
4. OUTCOMES OF CARE
For More Information
1
Goetze J. (2000). The JCAHO timeline. A Newsletter from Medical/Legal Consultants of Colorado,
2(5), 4-5. www.medical-legal-consultants.com/newsletter
2
Heart and Stroke Foundation of Canada. (1999). The Changing Face of Heart Disease and Stroke
in Canada 2000. Ottawa: Heart and Stroke Foundation of Canada.
3
Alter DA, Naylor CD, Austin P, Tu JV. (1999). Effects of socioeconomic status on access to invasive
cardiac procedures and on mortality after acute myocardial infarction. New England Journal of
Medicine, 341(18), 1359-1367.
4
Canadian Institute for Health Information. (2001). Health Care in Canada 2001. Ottawa: CIHI.
5
Tu JV, Austin P, Naylor D, Iron K, Zhang H. (1999). Acute myocardial infarction outcomes in
Ontario. In Naylor CD, Slaughter PM (Eds). Cardiovascular Health and Services in Ontario: An ICES
Atlas. Toronto: Institute for Clinical Evaluative Sciences.
6
Johansen H, Nair C, Mao L, Wolfson, M. (2002). Revascularization and heart attack outcomes.
Health Reports, 13(2), 35-46.
7
Kapral MK, Wang H, Mamdani M, Tu JV. (2002). Effect of socioeconomic status on treatment and
mortality after stroke. Stroke, 33, 268-275.
8
Stroke Unit Trialists’ Collaboration. (2001, April). Organised inpatient (stroke unit) care for stroke
(Cochrane Review). The Cochrane Library. www.updatesoftware.com/abstracts/ab000197.htm
9
Stroke Unit Trialists’ Collaboration. (1997). Collaborative systematic review of the randomised
trials of organised inpatient (stroke unit) care after stroke. British Medical Journal, 314,
1151-1159.
10
Canadian Institute for Health Information. (2001). Clinical utilization and outcomes. In Hospital
Report 2001: Acute Care. Ottawa: CIHI.
11
Benbassat J, Taragin M. (2000). Hospital readmissions as a measure of quality of health care:
Advantages and limitations. Archives of Internal Medicine, 160(8), 1074-1081.
12
Dönges K, Schiele R, Gitt A, Wienbergen H, Schneider S, Zahn R, Grube R, Baumgartel B, Glunz
HG, Senges J. (2001). Incidence, determinants, and clinical course of reinfarction in-hospital after
index acute myocardial infarction (results from the pooled data of the Maximal Individual Therapy
in Acute Myocardial Infarction (MITRA) and the Myocardial Infarction Registry (MIR)). American
Journal of Cardiology, 87(9), 1039-1044.
13
Heller RF, Fisher JD, D’Este CA, Lim LL, Dobson AJ, Porter R. (2000). Death and readmission in
the year after hospital admission with cardiovascular disease: The Hunter Area Heart and Stroke
Register. Medical Journal of Australia, 172(6), 261-265.
14
McCaul KA, Wakefield MA, Roder DM, Ruffin RE, Heard AR, Alpers JH, Staugas RE. (2000).
Trends in hospital readmission for asthma: Has the Australian National Asthma Campaign had an
effect? Medical Journal of Australia, 172(2), 62-66.
15
Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. (1997). The association between the
quality of inpatient care and early readmission: A metaanalysis of the evidence. Medical Care,
35(10), 1044-1059.
16
Maynard C, Every NR, Weaver WD. (1997). Factors associated with rehospitalization in patients
with acute myocardial infarction. American Journal of Cardiology, 80(6), 777-779.
17
Baker GR, Anderson GM, Brown AD, McKillop I, Montgomery C, Murray MA, Pink GH. (1999).
The Hospital Report ‘99: A Balanced Scorecard for Ontario Acute Care Hospitals. Toronto: Ontario
Hospital Association.
18
National Cancer Institute of Canada. (2001). Canadian Cancer Statistics 2001.
Toronto, Canada. http://66.59.133.166/stats/pdf/stats01e.pdf
19
Morrison H, Schanzer D. (1999). Measuring Up: A Health Surveillance Update on Canadian
Children and Youth. www.hc-sc.gc.ca/hpb/lcdc/brch/measuring/mu_g_e.html
20
Humar A, Leone JP, Matas, AJ. (1997). Kidney transplantation: A brief review. Frontiers in
Bioscience, 2, 41-47. www.bioscience.org/1997/v2/e/humar/humar.pdf
21
Clinical Islet Transplant Program. (2002). History of the Islet Transplant Program.
www.med.ualberta.ca/islet/hist.html
22
Canadian Diabetes Association. (2001, October 19). The Edmonton Protocol: Islet Cell Transplant
One Year Later. Ottawa: Canadian Diabetes Association.
www. newswire.ca/releases/October2001/19/c7240.html
23
Canadian Institute for Health Information. (2001). 2001 Report, Volume 2: Organ Donation and
Transplantation, Canadian Organ Replacement Register. Ottawa: CIHI.
24
United Network for Organ Sharing. (2002). Living Donation: An Overview.
www.unos.org/Newsroom/critdata_livingdonor.htm
25
Tarantino A. (2000). Why should we implement living donation in renal transplantation? Clinical
Nephrology, 53(4), 55-63.
26
Canadian Institute for Health Information. (2001). Estimating Potential Cadaveric Organ Donors
for Canada and its Provinces, 1992 to 1998: A Discussion Paper. Ottawa: CIHI.
www.cihi.ca/pdf/PotCadaveric.pdf
57
HEALTH CARE IN CANADA 2002
Public Advisory Group on Xenotransplantation. (2001). Executive Summary: Animal-to-Human
Transplantation: Should Canada Proceed? A Public Consultation on Xenotransplantation. Ottawa:
Canadian Public Health Association. www.xeno.cpha.ca/english/execsumm/execsume.pdf
28
Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. (2000). Selective referral to highvolume hospitals: Estimating potentially avoidable deaths. Journal of the American Medical
Association, 283(9), 1159-1166.
29
Hamilton BH, Ho V. (1998). Does practice make perfect? Examining the relationship between
hospital surgical outcomes for hip fracture patients in Quebec. Medical Care, 36(6), 892-903.
30
Simunovic M, To T, Theriault M, Langer B. (1999). Relation between hospital surgical volume and
outcome for pancreatic resection for neoplasm in a publicly funded health care system. Canadian
Medical Association Journal, 160(5), 643-648.
31
Sinclair CM. (2000). The Pediatric Cardiac Surgery Inquest Report.
www.pediatriccardiacinquest.mb.ca/toc/toc.html.
32
Canadian Intergovernmental Conference Secretariat. (2002). Provinces Pave the Way for the
Future of Health Care. Provincial-Territorial Premiers’ Meeting January 24-25, 2002, News Release.
www.scics.gc.ca/cinfo02/850085004_e.html
33
Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, Welch G, Wennberg DE.
(2002). Hospital volume and surgical mortality in the United States. New England Journal of
Medicine, 346(15), 1128-1137.
34
Epstein AM. (2002). Volume and outcome—It is time to move ahead. New England Journal of
Medicine, 346(15), 1161-1164.
35
Laffel G, Barnett AI, Finkelstein S, Kaye MP. (1992). The relationship between experience and
outcome in heart transplantation. New England Journal of Medicine, 327, 1220-1225.
36
Farley DE, Ozminkowski RJ. (1992). Volume-outcome relationships and inhospital mortality: The
effect of changes in volume over time. Medical Care, 30(1), 77-94.
37
Luft HS, Hunt SS, Maerki SC. (1987). The volume-outcome relationship: Practice makes perfect or
selective referral patterns? Health Services Research, 22(2), 157-182.
27
58
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
5. Public Health: On Guard Year
After Year
In the mid-1800s in London, England, nearly 600 people died in a cholera
epidemic. Although popular theory at that time suggested that cholera was
airborne, Dr. John Snow set out to prove that it spread through contaminated water.
He focused on two water companies that both used the Thames River as their
source. He then mapped which houses received water from which company. Dr.
Snow found that houses receiving water from the Southwark and Vauxhall Company
had more than eight times the number of cholera deaths, than did others.1
A few months later, an outbreak occurred in the Soho district. Again, Dr. Snow
interviewed family members of the sick, patrolled the area, and mapped out
deaths. He found that almost all deaths happened close to a water pump on the
corner of Broad and Cambridge Streets.2 Convinced of the connection between the
pump and the deaths, he had the authorities disable the Broad Street pump. The
number of cholera cases fell dramatically. Ultimately, Dr. Snow’s groundbreaking
discoveries led to legislation mandating the filtration of drinking water.
Recent outbreaks in Walkerton, North Battleford, and elsewhere remind us that
safe water is as essential for health today as in the 1800s. Public health has had
impressive victories since that time. They have significantly improved health and
reduced the burden of disease in Canada and around the world. But experience
has shown that constant vigilance and on-going action are required to capitalize
on and maintain these gains. And challenges, such as HIV, continue to emerge.
Traditionally, public health focused on controlling infectious diseases through
vaccination, food and water safety, and other activities. Many programs also
evolved to detect diseases early using routine screening tests and to educate
Canadians about personal behaviours that affect health. The “new public health”
goes even further. It is concerned with a broad range of health determinants,
including early childhood development; social policies and practices; and
interactions among biological, social, cultural, and environmental factors.3 This
approach often involves a combination of interventions at different levels with a
variety of partners.
This chapter describes a sample of the wide variety of public health initiatives
underway across the country.
HEALTH CARE IN CANADA 2002
An International Vision for
Health Promotion
In 1986, experts from around the world endorsed
the Ottawa Charter for Health Promotion.4 Its broad
vision of the determinants of health and need for
inter-sectoral action for health continues to inform
today’s health policy debates.
The Charter argues that the fundamental
conditions and resources for health are peace, shelter,
education, food, income, a stable ecosystem,
sustainable resources, social justice, and equity. It
calls for coordinated action to build healthy public
policy, create supportive environments, strengthen
community action for health, develop personal health
skills, and reorient health services.
Containing Disease
Major killers from the past—such as
smallpox, polio, cholera, measles, and the
plague—are gone or very rare in Canada
today, but many challenges remain. For
example, communicable diseases continue
to affect thousands of Canadians each
year. These diseases are transmitted directly
or indirectly from one person to another.
Health protection and disease prevention
programs are designed to anticipate,
avoid, and address these and other
immediate and imminent threats to health.
In this section, we focus on four
examples—monitoring the safety of water
supplies, routine vaccinations, syphilis
control, and cancer screening programs.
Drinking Water Safety
Human life depends on water, but
contaminated water can kill. About a
billion people living in developing countries
are at risk because they are without clean
drinking water, according to United
Nations estimates.5 Most Canadians are
more fortunate. We generally do have
access to safe drinking water. But, as
recent events have reminded us,
maintaining these systems requires
sustained effort and commitment.
60
Parasites, bacteria, viruses, and both
natural and “man-made” chemicals can all
contaminate drinking water. Unsafe food
and water can make us sick, often with
stomach or intestinal illness. Each year,
Health Canada receives reports about the
number of Canadians who become sick
with food and/or water-borne illnesses.
Campylobacteriosis, salmonellosis, and
giardiasis (“beaver fever”) were the most
common conditions reported on average
from 1994 to 1998.6 Many more cases go
unreported, partly because people with
milder symptoms may not seek professional
care for their illnesses. In fact, Health
Canada estimates that as few as 10% of all
cases may actually be reported.7 Likewise,
Ontario researchers estimate that only one
out of every four to eight cases of illnesses
related to E. coli are ever reported.8
Not all gastrointestinal illness is caused by
water-borne pathogens, but public health
professionals have made the link in a
number of cases. For example, a recent
Vancouver Water Study found that waterborne pathogens were present in the water
supply and had contributed to
gastrointestinal illness in Vancouver.9 Since
1985, there have been 18 outbreaks of
water-borne illness in British Columbia
alone.10 Similarly, a source well
contaminated with E. coli led to 1,346
reported cases of gastroenteritis and seven
deaths in Walkerton, Ontario in May 2000.11
About a year later, there was an outbreak of
cryptosporidiosis in North Battleford,
Saskatchewan.12 In this case, an equipment
breakdown at a water treatment plant
allowed a parasite into the water supply.
Between 5,800 and 7,100 people—almost
half the city’s population—became ill.
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Lessons from Walkerton
Walkerton’s experience offers hard-won lessons to
all parts of the country. Justice O’Connor led an
Inquiry to determine what happened. His recent
report included a wide range of recommendations to
ensure the safety of future water supplies, such as:
• All vacant Medical Officer of Health (MOH)
positions in the province should be filled. Local
MOH roles should be clarified and strengthened.
• The Ministry’s Public Health Branch should
continue to track trends in non-compliance
by Public Health Boards on a yearly basis to
assess whether program and service guidelines
or resources need to be changed to ensure
full compliance.
• The government should ensure adequate resources
so that inspections are thorough and effective.
• The Public Health Branch should provide written
guidance to MOHs, including the steps to be taken
once inspection reports and water sample test
results are received.
• Regular meetings should be scheduled to discuss
public health issues.
• A Boil Water Protocol should be developed,
outlining circumstances under which to issue boilwater advisories.
• The Ministry of the Environment (MOE) should
develop criteria for identifying “groundwater under
the direct influence of surface water” and maintain
information on quality of source water.
• Continuous chlorine and turbidity monitoring
should be implemented.
• All certificates of approval should be limited to
five years and subject to renewal with required
conditions added.
• Both announced and unannounced inspections
should be conducted, with unannounced
inspections at least once every three years.
Municipal water systems and systems with
significant deficiencies should be inspected at
least annually. The MOE should establish and
enforce time lines for preparation and delivery of
inspection reports.
• There should be standard certification for all water
system operators.
• The government should clearly define and
implement training and the MOE should devote
sufficient resources to technical training.
Ensuring Safe Drinking Water
By the time that water trickles out of a
tap, it has often had a long journey
through a complex water supply system.
Whether the source is an underground
spring or surface water, water can become
contaminated anywhere along the way
from the source to the tap.
Water Quality on First
Nations Reserves
For most Canadians, safe drinking water is as close
as the kitchen tap, but that’s not true for everyone. In
1978, almost half (about 47%) of homes on Canada’s
reserves did not have access to water delivery systems.13
By 1994/1995, almost all (94%) of these homes had
water supplies that met minimum standards according
to Indian and Northern Affairs Canada.
Nevertheless, a 1995 study of 863 on-reserve
water systems found a number of problems.14 One in
five systems (20%) had problems that could potentially
affect health, and one in 20 (5%) were in need of
serious repairs or improvements. In addition, more than
a quarter (26%) had non-health-related problems,
such as system capacity or water smell or taste.
The federal government reports that steps have been
taken to address many of these issues.13 And more than
three-quarters of First Nations and Inuit people
surveyed (78%) said that there was some or good
progress in water and sewage facilities on reserves
between about mid-1995 and mid-1997.15 Nevertheless,
the Assembly of First Nations reports some drinking
water systems on reserves still have problems.16
The Federal-Provincial-Territorial
Subcommittee on Drinking Water sets the
Guidelines for Canadian Drinking Water
Quality.17 These basic parameters are
relevant for all water systems: public,
semi-public, and private. The Guidelines
include the maximum acceptable
concentration of many microbiological,
chemical, physical, and radiological
agents in safe drinking water.
61
HEALTH CARE IN CANADA 2002
What Is, and What Can Be, Found in
Our Drinking Water?
50
The Guidelines for Canadian Drinking Water Quality lay out
maximum acceptable concentrations (MACs) for chemicals and
microbiological organisms in our water. Under these
guidelines, no coliforms, such as E. coli, should be detected in
our water supply. Varying amounts of chemicals are allowed,
depending on their expected affect on our health. Some
substances, such as calcium, are seen to have no health risk
and are not included in the Guidelines. Other agents not
covered in the guidelines, both natural and “man-made”, may
also be found in the water. In some situations, some of these—
like giardia, campylobacter, and cryptosporidium—may affect
our health.
giardia, campylobacter,
cryptosporidium, fecal
coliforms, cyclospora,
blue-green algae,
pesticides, disinfectors,
medications, cyanide,
arsenic, trihalomethanes
MACs
ß Nitrate-nitrogen: 10mg/L
ß Fluoride: 1.5mg/L
ß Cyanide: 0.2mg/L
ß Aluminum: 0.1mg/L
ß Lead: 0.01mg/L
ß Mercury: 0.001mg/L
ß Fecal Coliforms: 0.0/100mL
Source: Adapted from Guidelines for Canadian Drinking Water Quality, March 2001.
Each jurisdiction regulates and monitors
its supplies of drinking water, but processes
differ across the country. In most cases,
direct monitoring of water quality is a
local, municipal responsibility (water
treatment facilities are often owned and
operated by individual municipalities). The
regulatory framework within which this
occurs varies from place to place. For
example, only three provinces directly
apply the Guidelines as their standard;
three require operator training or
certification; five use certified or accredited
testing labs; six use provincial or agency
testing labs; and eight provinces/territories
have mandated disinfection.18
Some Canadians also choose to drink
bottled water. In a 1999 poll, about 40%
of Canadians reported drinking bottled
water in their homes.19 We drank an
average of over 23 litres per person in
1998, up from 18 litres in 1995.20
62
In comparison, we consumed more than
four times as much in soft drinks, alcohol
(based on population age fifteen and
over), and coffee.
The federal Food and Drugs Act regulates
bottled water and prepackaged ice. In
2000, the Canadian Food Inspection Agency
reviewed practices at 125 bottled-water
manufacturers.21 Most met the assessment
standards, but about 11% needed follow-up
action to ensure that appropriate controls
were in place.21 In a related study of bottled
water sold in retail outlets, all 148 samples
tested were satisfactory.
Boil-Water Advisories—An
Immediate but Temporary
Solution?
What happens when water is
contaminated? If the problem is bacteria,
boiling the water can be a solution.
Accordingly, regional and local health units
or authorities often issue boil-water
advisories when they learn of water
problems. These public health
announcements are often broadcast through
local and/or national radio, local television,
printed pamphlets, and other means.
In the case of disease outbreaks,
authorities usually keep the advisory in
place until rates of illness in the community
return to pre-outbreak levels. For example,
the Bruce-Grey-Owen Sound Health
Unit’s boil-water advisory related to
problems with Walkerton’s water
remained in effect for 199 days. The
resulting heightened awareness of waterborne illness may also have had spin-off
effects elsewhere in the country. For
example, British Columbia and
Newfoundland have tracked the number
of boil-water advisories over many years.
After the Walkerton outbreak, the number
of advisories issued rose sharply in
both provinces.
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Boiling Our Water
51
When high levels of some contaminants are found in drinking
water, public health officials may issue boil water advisories.
The number of advisories issued in a given period depends on
many factors such as increased testing, more contamination of
the water, or authorities adopting a more cautious approach to
reduce risk. The graph below shows the number of advisories
issued on the east and west coasts of the country
(Newfoundland and British Columbia) between 1987 and
2001, as well as two major events related to drinking water
quality that occurred in this period.
Trusting the Water
Very confident
10
9
8
300
# of boil water advisories issued
52
A 2001 national survey found that younger and older
Canadians express more confidence in drinking water than
those in the middle age groups. This difference in confidence
may reflect personal experience with the water supply, general
attitudes toward the public health system, or many other
factors. The graph below shows average confidence levels on
a scale of one to 10 by age group.
7
Walkerton E. coli
outbreak, 2000
250
6
BC Safe Drinking
Water Regulations
Introduced,
October 1992
200
5
4
150
3
100
2
50
Not at all
confident
BC
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
0
NF
Sources: Drinking Water Quality in British Columbia: The Public Health Perspective. A Report on the
Health of British Colombians. (2001). Ministry of Health Planning, Office of the Provincial Health
Officer; Boil Water Advisories for Community Water Supplies in Newfoundland and Labrador,
Departments of Environment and of Government Services and Lands, 1987-2001.
What Canadians Think
Most of us believe that the water in our
homes is safe to drink, according to an
Internet-based survey of about 800
Canadians in September 2001.22 On
average, respondents gave their water a
score of 6.9 on a ten-point scale, where one
was not at all confident and 10 was very
confident. People who said that they used
wells or municipal water supplies had
significantly more confidence in the safety of
the water (7.7 and 7.3 out of 10,
respectively) than those who said that they
drank bottled water (5.6 out of 10).
In another 2001 poll, 68% of respondents
reported that they were confident in the
quality of their drinking water.23 Men were
more likely than women to be extremely
confident in the quality of their drinking
water (37% versus 29%). In addition, people
living in Alberta and Quebec were more
1
0
16-24
25-34
35-49
Age group
50-64
65+
Source: Drinking Water Survey, Erin Research Inc. September, 2001.
confident in the quality of tapwater than
those living in other provinces. Ontarians
were less confident than those living in the
rest of the country.
A Shot in the Arm for
Public Health
Only clean water has had more impact on
public health than vaccinations, according to
the World Health Organization (WHO).24 The
world’s first vaccine was born in 1798 when
Edward Jenner showed that an injection of
cowpox—a not so deadly virus—protected
against smallpox.
Smallpox is thought to have originated in
India or Egypt over 3,000 years ago. For
centuries, epidemics swept across the world.
They left many people dead, disabled, or
disfigured. For example, in a survey
conducted in Vietnam in 1898, 95% of
adolescent children in were pockmarked,
and 90% of all blindness was attributed
to smallpox.25
63
HEALTH CARE IN CANADA 2002
WHO launched a campaign to eradicate
smallpox in 1956. A quarter century later,
they declared victory. Significant progress has
also been made on other diseases, such as
polio and measles. Nevertheless, ongoing
surveillance of communicable disease is
critical. Only through constant vigilance can
outbreaks be caught early and contained.
Beating Childhood Diseases
53
We can go back as far as 1924 to compare the number of
reported cases each year for selected diseases. These numbers
fluctuate, as this graph for measles cases in Canada shows.
Look at what has happened since the vaccine was introduced
in 1963.
90,000
80,000
Number of Reported Cases
70,000
60,000
50,000
Measles
1963
40,000
30,000
20,000
2001*
1994
1987
1980
1973
1966
1959
1952
1945
1938
1931
0
1924
10,000
Year
Measles
Note: 2000 and 2001 data are preliminary estimates. Where lines are broken,
no data are available.
Source: Division of Disease Surveillance, Centre for Infectious Disease Prevention
and Control, Health Canada.
Protecting Canadian Children
Canadian children are routinely
vaccinated against nine diseases: polio,
pertussis (whooping cough), tetanus,
diphtheria, Haemophilus influenzae type
b (Hib), measles, mumps, rubella, and
hepatitis B.
Each province and territory has
developed a routine schedule for
childhood vaccinations. These schedules
are substantially similar, but some
differences do exist.26 For example,
vaccinations for diphtheria, pertussis,
polio, and Hib are usually given at two,
64
four, six, and 18 months. A two-dose
measles-mumps-rubella (MMR) vaccine is
given around one year and again around
18 months. However, in Nova Scotia,
Ontario, Manitoba, and Alberta an MMR
is given at 12 months and between the
ages of four and six. There are also other
differences. For instance, the hepatitis B
vaccine is sometimes given in infancy and
sometimes in early adolescence.
The vaccination schedules continue to
evolve over time, partly because new
vaccines are introduced. For example, the
varicella vaccine against chickenpox was
licensed in Canada in 1998. It produces
immunity in between 70% and 90% of
those vaccinated, with relatively low risk
of side effects.27
Chickenpox mostly affects children. In
most cases, they recover quickly, but the
disease can be serious, even fatal,
particularly for adults. Potential
complications include bacterial infections
of the skin and soft tissue, pneumonia,
and encephalitis.28 Vaccination
campaigns hope to reduce the frequency
of these serious complications, as well as
health care costs and indirect costs (e.g.
lost wages for parents who stay home to
care for sick children).
Some provinces have implemented
routine childhood varicella vaccination.
For example, Prince Edward Island and
the Northwest Territories currently
administer a routine varicella vaccine to
children at age 12 months.26 And
Nunavut has plans to implement a
program in the summer of 2002. Alberta
has also phased in the vaccine as part of
its routine immunization schedule. In
April 2001, grade five students, health
care workers, families of
immunocompromised individuals, and
postpartum women who were found
during prenatal visits to be susceptible,
became eligible to receive the vaccine.
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Three months later, one-year-olds born in
the year 2000 were added to the list. And
beginning April 2002, children in Alberta
could receive the varicella vaccine with
their preschool booster if they were at
least four years of age.
Listening to Canadian Parents
In a survey conducted in 2001, almost all Canadian parents (about 90%) said they
believed it was important to vaccinate children.29 Over 90% also felt that:
• childhood vaccines take pressure off the health care system
• all children should be given all of the standard
vaccines
Childhood Immunization by Age One
55
• they would pay out-of-pocket for vaccines for their
As a signatory to the Declaration of the 1990 World Summit for
children
Children, Canada has established goals for immunization
• the government should fund all vaccines
coverage. Canada has achieved, for the most part, its target
Most Important Factors in Deciding
to Vaccinate Children
54
90
80
70
Benefits
outweigh risks
2%
60
50
40
Prevention
21%
30
20
Seriousness of
the disease
6%
Safety
15%
Oman
Iran
Japan
Hungary
Turkmenistan
Tonga
Slovakia
Portugal
CANADA
UK
France
Italy
US
Germany
Algeria
% Age 1, DPT immunized
Netherlands
Recommendation
from doctor
15%
0
Australia
Are there/what
are the side
effects?
6%
10
Venezuela
Required by
school/daycare
3%
Niger
Effectiveness
12%
Somalia
Missing
13%
100
% Vaccinated
A recent telephone survey questioned parents about their
attitudes towards immunization. Most thought that vaccinating
their children was very important. They said that several factors
played a role in their decisions about whether or not to have
their children vaccinated. Disease prevention, doctor’s
recommendations, and vaccine safety were most often
mentioned as considerations.
vaccination rates of 95-97% by age one for diphtheriapertussis-tetanus (DPT) and for measles. Some countries report
achieving even higher rates of childhood vaccination for these
diseases. Others, including several G7 countries, have lower
rates as the chart below shows.
% Age 1, measles immunized
Source: The State of the World’s Children, 2000. UNICEF
Risk level of the
disease
7%
Source: Canadian Immunization Survey, in Coalition for the Canadian Public Health Association in
consultation with Coalition for the Canadian Immunization Awareness Program and the Canadian
Coalition for Influenza Immunization. (2001). The Value of Immunization in the Future of Canada’s
Health System. Submission to the Commission on the Future of Health Care in Canada.
65
HEALTH CARE IN CANADA 2002
Flu Shots for Adults
Influenza, commonly called ‘the flu’,
typically comes on fast and brings
headache, fever, chills, cough, muscle
aches, and tiredness. Healthy people
usually recover from the flu in a few days.
However, for some people, complications
from the flu can be much more serious
and even life threatening.
Getting a flu shot each year can not only
protect you from getting the flu, it can also
minimize the symptoms if you do get it.
Vaccination also helps stop the flu’s spread
from person to person. Because the virus
changes from year to year, people must
get vaccinated each year to retain the
protective effect.
In 2000/2001, Statistics Canada asked
Canadians if they had had a flu shot in the
last year. About two in three seniors (65%)
said they had, compared to 51% in
1996/1997. Flu shot rates for seniors
ranged from a low of 45% in Newfoundland
to a high of 71% in Nova Scotia.
Who’s Getting Their Flu Shots?
Vaccination rates are rising. Overall in
2000/2001, 27% of Canadians aged 12
and older reported having a flu shot in the
last year, up from just under 15% in
1996/1997. The overall rise in vaccination
rates may be partly explained by broad
public awareness campaigns and increasing
public coverage of the costs of the shots.
Almost all provinces and territories fund flu
shots for people in specific high-risk groups
or for those in regular contact with high-risk
groups. Some go further. For instance,
Ontario has offered to pay for flu shots for
all residents since 2000.
Whose Flu Shots are Funded
57
As of March 2000, most provinces/territories had some publicly
funded flu vaccination program for high-risk groups, as the chart
below shows. Several provinces had planned to expand their
programs to cover a broader range of groups at this point. In
some cases, such as Ontario, programs recently expanded to
cover all residents.
56
According to the Canadian Community Health Survey
(2000/2001), more Canadians are getting their flu shots
compared to five years ago. The overall Canadian average
went from just under 15% of teens and adults in 1996/1997
to over 27% in 2000/2001.
50
45
% reported flu shot in last year
40
35
30
25
20
15
10
l Risk group is covered by a publicly funded program
m Planned expansion of program to include group
5 Risk group not covered
* > 55
5
0
NF
PEI
NS
NB
QC
ON
1996/1997
MB
SK
AB
BC
CA
2000/2001
Sources: National Population Health Survey (1996/1997);
Canadian Community Health Survey (2000/2001), Statistics Canada.
66
Source: Squires SG, Pelletier L. (2000). Publicly-funded influenza
and pneumococcal immunization programs in Canada: A progress report.
Canadian Communicable Disease Report, 26(17), 141-148.
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Syphilis: The Promise
and the Threat
Not long ago, Canadian public health
experts wrote encouragingly about the
possibility of eliminating the local
transmission of syphilis.30 The number of
new cases had been falling in Canada
since the 1940s. The national rate was
between 0.4 and 0.6 per 100,000
population between 1994 and 2000.31
These trends, along with the characteristics
of the disease and the availability of
effective treatment, offered hope that
syphilis could be the first sexually
transmitted disease to be eliminated,
they argued.
But the threat is not yet gone. Projections,
based on the first nine months of data,
suggest a resurgence in 2001, possibly up
to 0.9 per 100,000.31 Rates are up for both
men and women. There have been a
number of recent local outbreaks in
different parts of the country, including one
associated with the sex trade in
Vancouver’s downtown eastside that started
in mid-1997. In spite of many initiatives by
public health authorities, the number of
reported infectious syphilis cases in BC in
2001 (177) was almost 10 times higher
than the 18 cases reported in 1996.32
Women’s Health:
Screening for Breast
and Cervical Cancer
The premise of most screening
programs is simple—catch a disease or
the presence of its risk factors early and
prevention or treatment may be more
effective. In some cases, it may be
possible to prevent a disease entirely, or at
least to significantly reduce its effects.
In some cases, screening makes sense.
In others, it is not appropriate. The
balance depends on how common the
condition is in the target population, how
likely the test is to detect it when it is
present and not otherwise, whether
effective prevention or treatment strategies
exist, and much more.
The Canadian Task Force on Preventive
Health Care weighs the evidence on what
should—and should not—be included in
regular checkups for Canadians of
different ages. Two areas where they
recommend routine screening are cervical
and breast cancer.
About 1,400 new cases of cervical
cancer will be diagnosed in Canada this
year.33 That’s about 7.8 cases per 100,000
Canadian women, down from 9.6 a
decade earlier and 12.3 in 1982.
Changes in a number of risk factors, such
as smoking and sexual behaviours, may
have contributed to this trend.
Pap smears test a sample of cervical
cells for abnormalities. They are designed
to catch pre-cancerous and cancerous
conditions early to facilitate treatment. The
Canadian Task Force on Preventive Health
Care recommends regular pap smears for
women from when they become sexually
active or turn 18 (whichever is earlier) until
age 69.
Breast cancer is the most frequently
diagnosed cancer among Canadian
women.33 Almost one in ten is likely to
develop breast cancer in her lifetime, and
one in 26 is expected to die from it.34
First used in clinical practice in 1927,
mammography or breast imaging is used
to identify breast abnormalities. By the
1950’s and 60’s, the technology was
further developed so that benign breast
anomalies could be distinguished from
malignant breast disease.
More recent advances have led to tools
that can be used for mass-screening
programs. In 1988, British Columbia was
the first province to implement an
organized screening program for breast
cancer. This type of program is now
67
HEALTH CARE IN CANADA 2002
available across the country, at least for
women aged 50 to 69.
There is an on-going scientific debate
about exactly who should receive regular
screening for breast cancer. A number of
studies suggest that mammography
screening can reduce breast cancer deaths,
particularly in women from age 50 to
69.35,36,37 On the other hand, a recent review
of randomized trials concluded that there
was a lack of reliable evidence showing that
Pap Smear and Mammogram
Rates Across the Country
58
It is recommended in Canada that women aged 50 to 69 have
a mammogram every two years. For Pap smears, the
recommendation is every three years for women aged 18 to
69. Overall, the rates for recent mammograms are increasing.
About 70% of women had a recent mammogram (for
screening or other reasons) in 2000/2001, compared to 63%
in 1996/1997.
Trend in Recent Mammograms and Pap Smears for Canada*
100
90
80
70
% reported
60
50
40
30
20
10
0
1996/1997
1998/1999
Mammograms
2000/2001
Pap smears
* Excludes those who answered don’t know or those who did not answer to ensure
comparability across years.
Recent Mammograms and Pap Smears by Province in 2000/2001
100
90
80
% reported
70
60
50
40
30
20
10
0
NF
PEI
NS
NB
QC
Mammograms
ON
MB
SK
AB
BC
CA
Pap smears
Sources: National Population Health Survey (1996/1997 & 1998/1999) and Canadian
Community Health Survey (2000/2001), Statistics Canada.
68
mammography reduces overall death rates
and some evidence that it may lead to more
aggressive treatment.38
Nevertheless, a panel of experts recently
convened by the World Health Organization
reconfirmed its support for mammography.
The experts agreed that screening could
reduce the chance of dying from breast
cancer among women aged 50 to 69 by
about 35%.39 The National Cancer Institute
in the United States also continues to
recommend that women 40 and older be
screened every one to two years.40 The
Canadian Task Force on Preventive Health
Care recommends routine screening for a
smaller target group: women between 50
and 69 years of age.41
Who’s Being Screened?
A series of Statistics Canada surveys have asked women
about their participation in cancer screening programs over
several years.
The 2000/2001 Canadian Community Health Survey found
the percent of women aged 50 to 69 who reported having a
mammogram in the last two years for any reason was about
70%.42 About 75% said that they received the mammogram
as part of their regular check-up or routine screening. The rest
had mammography for a variety of reasons including their
age, family history of breast cancer, previously detected lump,
and other reasons. In 2000/2001:
• More women who had a regular doctor reported
getting mammograms than those who did not have a
regular doctor.
• Women with higher incomes and higher levels of
education were also more likely to have had a recent
mammogram.
The percent of women who reported having a recent Pap
smear was about 73% in 2000/2001. What makes some
women get regular Pap smears and not others? In
2000/2001:
• More women who had a regular doctor had a recent Pap
smear (75%) than those who did not have a regular
doctor (57%).
• Older (64%) and younger (60%) women were less likely
to report having a recent Pap smear than women
between 25 and 54 (78%).
• Women with higher income (80%) and higher levels
of education (79%) were more likely to have a recent
Pap smear.
i
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Getting the Message
Out: Snapshots of
Health Promotion in
Canada
Healthy Futures
The choices we make can support
health—or can harm it. A range of health
promotion programs focus on getting the
latest evidence about what helps and what
hurts to Canadians. There are media
campaigns designed to help reduce
smoking, excessive alcohol consumption,
or unhealthy eating. Other programs try to
get the word out in playgrounds, schools,
workplaces, doctors’ offices, and
elsewhere. These initiatives often involve a
wide range of partners, both within and
outside the traditional health care sector.
Examples include governments at all levels,
voluntary organizations, faith or mutual aid
groups, and the business community.
Promoting Health and Preventing
Illness in Doctor’s Offices
59
Most family doctors responding to the 2001 National Family
Physician Survey said that they frequently or very frequently
provide a range of health promotion and disease prevention
services to patients when needed. The degree to which particular
services are provided varies somewhat, as shown below.
Clinical breast examination for women aged 50-69
Mammography for women aged 50-69
The evidence is mounting—what
happens to us early in our development
can profoundly affect our health later in
life.43 For example, researchers now believe
that low birth weight is related to our
lifelong health and well being. As well,
our risk of developing diabetes, obesity,
and cardiovascular disease later in life
have all been linked to factors in our
developmental years.
In response, governments are dedicating
significant resources to improve the health
of children and their families.44 The goal is
to offer all Canadian children a solid
foundation at the beginning of their lives
on which to build strong, productive, and
healthy futures.
Of course, governments are not alone in
promoting healthy futures for Canada’s
children. Take, for example, the national
“Back to Sleep” campaign.45 Its goal was to
reduce the incidence of sudden infant death
syndrome (SIDS) or “crib death” by 10%
over five years. How? The campaign aimed
to increase awareness about SIDS risk
factors among parents, caregivers, and
health professionals. It used brochures, ads,
public service announcements, messages
on diaper waistbands, and other means to
spread evidence-based messages.
Outreach strategies for flu shots
Flu shots for the elderly
Counseling about breast feeding
Counseling about periconceptual folic acid supplementation
Smoking cessation counseling/interventions
Obtain history of tobacco use
Counseling on safe sex practices
Counseling about regular physical activity
Childhood immunization
Pap smears
Blood pressure screening
0
20
40
60
80
100
% of FP/GPs who report “very frequently” providing this service
% of FP/GPs who report “frequently” providing this service
Source: National Family Physician Workforce Survey Database, part
of the JANUS Project, College of Family Physicians of Canada.
69
HEALTH CARE IN CANADA 2002
A Childhood Obesity Snapshot:
What We Know...What We Need
To Know
• Levels of obesity among children aged seven to 13 have
nearly tripled in Canada over the past two decades.46 They
rose from 5% in 1981 to 16.6% in 1996 for boys and from
5% in 1981 to 14.6% in 1996 for girls.
• Canada’s children are considerably more likely to be
overweight than English, Scottish, and Spanish children,
among others.46
• Childhood obesity raises the risk of adult obesity, which is
linked to heart disease, diabetes, and other health problems.47
• Researchers have estimated that $829.4 million to $3.5 billion
of Canada’s health spending in 1997 was attributable
to obesity.48
• Inactivity plays a central role in childhood obesity. Fewer than
half of Canadian girls and boys are active enough to
benefit health.49
• A growing body of evidence indicates that interventions to
increase physical activity can effectively reduce obesity and
prevent type 2 diabetes.50
• A number of strategies to prevent obesity, from infancy to
adolescence and beyond, have been used. Some are
multi-pronged and involve families, schools, and communities.
A recent systematic review suggested that more evidence is
needed to determine which of the broad range of possible
strategies works best in what circumstances, not only in terms
of their immediate effects on children but also their impacts
on obesity and disease in adulthood.51
It is not possible to say definitively that
the campaign caused these changes.
Other programs or factors may have
contributed to the trends. What we can say
is that over the period that the campaign
was in place, for the audience that it
targeted, SIDS-related awareness and
behaviours improved.
When Will You Quit?
Smoking remains one of Canada’s
leading public health challenges. Smokingrelated diseases are a major source of
illness, health care costs, lost productivity,
and death.
Almost 22% of Canadians aged 12 or
older said that they smoked cigarettes daily
in the 2000/2001 Canadian Community
Health Survey, including 13% of 12 to 19
year olds and 10% of those 65 and older.
The percentage of Canadians who reported
smoking daily has decreased, especially
since 1978/1979. But 5.5 million of those
12 and older continue to smoke.
Canadian Smokers Then and Now
60
According to Statistics Canada, 37% of Canadians 15 years
and older reported smoking cigarettes daily in 1978/1979. In
1998/1999, only 24% of Canadians reported smoking daily.
50
45
% of Canadians 15 and older who are daily smokers
Is the program working? It’s too soon to
know what has happened to SIDS death
rates, but early research is available on
trends in awareness and behaviours.
Partners surveyed current and prospective
parents before (in 1999) and after (in
2001) the campaign. Respondents in the
later survey were more likely to know that
infants who sleep on their backs have a
lower risk of SIDS. Awareness rose from
44% to 66%. In addition, more than twothirds of parents (69%) actually laid babies
on their back to sleep, up from 41% in
1999. Lastly, researchers also found that
health professionals who cared for infants
were more likely to recommend a back
sleeping position (67% in 2001 compared
with 21% in 1999).
40
35
30
25
20
15
10
5
0
All ages
15-19
20-24
25-44
1978/1979
1998/1999
45-64
65+
Source: Statistics Canada. (1999). How healthy are Canadians? A Special Issue.
Health Reports, 11(3), 83-90.
70
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Over the years, much effort and energy
has been devoted to both advertising
cigarettes and to encouraging smokers to
quit. A wide variety of strategies have been
used to increase awareness of the health
risks of smoking and to promote smoking
cessation, not all of which are equally
effective. Examples include requiring health
messages on cigarette packages, restricting
advertising, changing taxation levels,
conducting public awareness campaigns,
counseling from health professionals, and
much more.
Cigarette Packaging Pictures
61
Smoking cigarettes increases the risk of lung cancer, heart
disease, stroke, mouth disease, bronchitis, emphysema, and
even impotence. Public health programs use many strategies to
encourage smoking cessation, including banning the use of
“light” and “mild” labels on packaging, banning tobacco
company sponsorship of cultural events, and increasing taxes
on tobacco products. Recently, Health Canada has also
required cigarette packaging to show large warning messages
coupled with graphic pictures of damage done by smoking.
There are also many different aids to help
people quit. For example, you can chew
nicotine gum, wear a patch, use a nasal
spray or inhaled nicotine, or take nicotine
tablets or a prescription drug. The good
news is that they all seem to work, to some
degree. A systematic review of the literature
in 2001 found that all commercially
available treatments can be effective as part
of a smoking cessation plan.52 And the
research continues. For example, another
study published in 2001 looked at how likely
people using different types of aids were to
quit for at least seven days during the study
period. Researchers found that quit rates
were higher for those who used a nicotine
patch or the prescription drug bupropion
than for those who used other treatments
such as nicotine gum, nicotine inhalers,
hypnosis, quit smoking classes, or telephone
counseling.53
The bad news is that some people never
quit, even temporarily, and others start
smoking again.
Reducing Harm: HIV
Infection as an Example
HIV arrived in Canada in about 1982.
Unsafe sex practices are one way that the
virus is spread. Increasing the awareness of
those at risk and influencing their behaviour
are the focus of many health promotion
activities in Canada and around the world.
For example, recent media campaigns
targeted at higher risk groups, such as men
who have sex with other men, promoted
safer sex practices. Information about HIV is
also included in health education programs
for teens and free condoms are frequently
distributed, including to those participating in
events like the Olympic Games.
HIV infection can also be spread through
the use of infected needles or syringes. Of
the 23,771 positive HIV tests reported to
Health Canada’s Centre for Infectious
Disease Prevention and Control since 1985
where the risk exposure was known, almost
16% were attributable to injection drug use.54
Many attempts have been made to reduce
the risk that HIV will be spread through
injection drug use. Needle exchange
programs (NEPs) are one somewhat
controversial approach. They allow injection
drug users to exchange used needles and/or
syringes for clean sterilized ones. As of May
2001, there were approximately 200 NEPs
in Canada.55
Opponents believe that NEPs can cause
harm by creating new social networks for
injection drug users, encouraging people to
start injecting drugs, increasing the
frequency of injecting, and increasing
overall levels of drug use in a community.56
71
HEALTH CARE IN CANADA 2002
Proponents point to research that
suggests that NEPs do not encourage drug
use.57,58 They also argue that several studies
have shown that NEPs reduce the spread of
HIV.59,60,61 Further, a 2001 review of the
literature found that two-thirds (28/42) of
published studies showed positive effects
from NEPs, such as declines in needle
sharing.62 Recent studies in Hamilton and
Edmonton found that the costs of local
needle exchange programs were more
than offset by potential savings in health
care costs.59,60
Coping with
Emergencies
The September 11th, 2001 terrorist
attacks in the United States have reinforced
the awareness of importance of emergency
preparedness worldwide. The public health
system has an important role in designing
provisions to protect us, our communities,
and our environment in the face of smalland large-scale emergencies.
Who Responds?
Typically, the responsibility to respond to
an emergency lies first with the affected
municipalities. Depending on the scale of the
emergency, provincial and territorial
governments may be involved next. When
they need to, they can ask the federal
government for help, who can then invoke
the help of the Canadian Forces if need be.
The Office of Critical Infrastructure Protection
and Emergency Preparedness Canada is the
federal agency responsible for dealing with
emergency situations under the Emergencies
Act.64 The various levels of government also
work with non-governmental organizations,
such as the Red Cross, when necessary.
Following on the heels of the events of
September 11th, many governments and
organizations have recently reviewed, and in
some cases strengthened, their emergency
plans. For example, the federal government
72
recently announced new funding to improve
Canada’s ability to effectively respond to
public health crises and to chemical,
biological, radiological, and nuclear
incidents.65,66
The Capacity to Respond
to a Crisis: What Public
Health Officials Think
Federal, provincial, and territorial governments
recently surveyed public health professionals on the
capacity of our public health system to respond to
ongoing, emerging, and urgent issues.63 They
identified both strengths and weaknesses in Canada’s
system. Strengths included the experience,
knowledge, and skills of those working in public
health; the system’s credibility with the public; and its
ability to access and mobilize resources. Weaknesses
included regional differences in levels of service; lack
of focus on emerging issues, such as injury and
disease prevention; and public health staffing issues.
What Public Health Professionals Think
62
The ability to access and mobilize resources is very important
when dealing with outbreaks of communicable disease and
other public health concerns. Federal, provincial, and territorial
governments commissioned a recent survey of the capacity of
our public health system in 2001. Most people working in
public health said they believed the system would be able to
effectively mobilize in the event of a communicable disease
emergency. However, confidence varies somewhat depending
on who you ask, as shown below.
F/P/T health
protection staff (e.g.
food and water
safety inspectors)
F/P/T disease/injury
protection staff (e.g.
clinicians providing
immunizations)
Community-level
staff overall
Staff from
Aboriginal agencies
0
20
40
60
80
100
% Who agree public health is able to mobilize in a communicable disease emergency
Source: Advisory Committee on Population Health. (2001). Survey of Public Health Capacity in
Canada, Highlights. Report to the Federal, Provincial and Territorial Deputy Ministers of Health.
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
Information Gaps—Some Examples
What We Know
• Reported rates of selected communicable diseases.
• How confident Canadians are about the safety of their drinking water.
• How Canada’s childhood immunization rates for DPT and measles compare to those
in other countries.
• How many people receive flu shots in different parts of the country and the coverage
of public funding for flu shots in each province/territory.
• Use of selected screening services (e.g. mammograms and Pap smears) by
province/territory and health region.
• Self-reported rates of selected health-related behaviours (e.g. smoking, alcohol use,
and physical activity).
What We Don’t Know
• How many Canadians become ill each year because of unsafe food or water? What
are the short- and long-term health consequences of their illnesses?
• How many children receive all recommended immunizations on schedule?
• Which among the wide variety of possible health promotion strategies, many of
which aim to influence health outcomes far into the future, offer the most health
gains relative to resources expended?
• How do voluntary, community, and mutual aid groups, as well as the corporate
sector, contribute to health promotion, disease prevention, and health protection efforts?
What’s Happening
• Canada’s premiers and the prime minister agreed to track and report on the
adequacy of health protection/promotion services, along with other indicators, in
each of their jurisdictions by September 2002.
• The Canadian Population Health Initiative, part of CIHI, is providing funding to
support both new population health research and research synthesis in a number of
areas, including obesity.
• Health Canada has launched a new National Studies on Acute Gastrointestinal
Illness (NSAGI) initiative to investigate the magnitude, extent of underreporting,
etiology, burden of illness, and risk factors associated with gastrointestinal illness.
The first phase of NSAGI will focus on getting an accurate estimate of the baseline
rates of acute GI in Canada, through community-based population and physician
studies, as well as public health unit and laboratory surveys.
• Development of a National Immunization Records Network, including immunization
and adverse events surveillance, is underway. The aim is to have it up and running
by the year 2003.
73
HEALTH CARE IN CANADA 2002
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Lilienfeld DE, Stolley PD. (1994). Foundations of Epidemiology, 3rd ed. New York: Oxford
University Press.
2
University of California, Los Angeles Campus. (2001). Broad Street Pump Outbreak, Department
of Epidemiology, School of Public Health. www.ph.ucla.edu/epi/snow/broadstreetpump.html.
3
Federal, Provincial, Territorial Advisory Committee on Population Health. (1999). Toward a
Healthy Future: Second Report on the Health of Canadians. Ottawa: Health Canada.
4
International Conference on Health Promotion, Co-Sponsored by the Canadian Public Health
Association, Health and Welfare Canada, and the World Health Organization. (1986). Ottawa
Charter for Health Promotion. www.who.int/hpr/archive/docs/ottawa.html.
5
United Nations Development Program. (2001). Human Development Report 2001: Making New
Technologies Work for Human Development. www.undp.org/hdr2001.
6
Health Canada. (2001). Disease Surveillance On-Line: Notifiable Diseases On-Line Chart Query.
Ottawa: Population and Public Health Branch, Health Canada. cythera.ic.gc.ca/dsol/ndis/list_e.html.
7
Information, Analysis, and Connectivity Branch, Health Canada. (2001). Departmental
Performance Report 2000-2001, Annex A: Measuring Health in Canada. Ottawa: Health Canada.
8
Michel P, Wilson JB, Martin SW, Clarke RC, McEwen SA, Gyles CL. (2000). Estimation of the
under-reporting rate for the surveillance of Escherichia coli O157:H7 cases in Ontario, Canada.
Epidemiology and Infection, 125(1), 35-45.
9
Aramini J, McLean M, Wilson J, Holt J, Copes R, Allen B, Sears W. (2000). Drinking Water Quality
and Health Care Utilization for Gastrointestinal Illness in Greater Vancouver. Ottawa: Health Canada.
10
British Columbia Ministry of Health. (2000). Water Borne Diseases in B.C.
www.healthservices.gov.bc.ca/hlthfile/hfile49a.html.
11
O’Connor DR. (2002). The Walkerton Inquiry (2000-2001). Report of the Walkerton Inquiry: The
Events of May 2000 and Related Issues. www.walkertoninquiry.com/index.html.
12
Stirling R, Aramini J, Ellis A, Lim G, Meyers R, Fleury M, Werker D. (2001). North Battleford,
Saskatchewan, Spring 2001: Waterborne Cryptosporidiosis Outbreak. Ottawa: Health Canada.
13
Indian and Northern Affairs Canada. (2001). INAC and Canadian Polar Commission 1996-1997
Estimates. www.inac.gc.ca/pr/est/me3/pnp/ptb/iip/214_e.html.
14
Medical Services Branch, Health Canada and Corporate Services, Department of Indian Affairs
and Northern Development. (1995). Community Drinking Water and Sewage Treatment in First
Nation Communities. Ottawa: Health Canada and DIAND.
15
Svenson KA, Lafontaine C. (1999). The Search for Wellness. In National Report of the First
Nations and Inuit Regional Health Survey. Ottawa: First Nations and Inuit Regional Health Survey
National Steering Committee.
16
Assembly of First Nations. (2001). Fact Sheet: Safety of First Nations Drinking Water.
www.afn.ca/programs/health%20secretariat/factsheets/fs%2Ddrinkingwater%2De.pdf.
17
Federal/Provincial/Territorial Subcommittee on Drinking Water. (2001). Summary of Guidelines for
Canadian Drinking Water Quality. Ottawa: F/P/T/Subcommittee on Drinking Water.
18
Christensen R, Parfitt B. (2001). Waterproof: Canada’s Drinking Water Report Card. Sierra Legal
Defence Fund.
19
Berger (2001). Population Health Monitor. March 1999 Survey Overview Report. Toronto:
HayGroup.
20
Statistics Canada. (2000). Food Consumption in Canada: Part 1. Ottawa: Statistics Canada.
Catalogue no. 32-229-XPB.
21
Canadian Food Inspection Agency. (2002). Bottled Water–is it a Safety Concern? Frontline.
www.inspection.gc.ca/english/corpaffr/publications/flag/2002-03e.shtml#h2o.
22
Erin Research Incorporated. (2001). Drinking Water Survey. Erin: Erin Research Incorporated.
23
Leger Marketing. (2001). Perception and Behaviour of Canadians With Regards to Drinking
Water. Canadian Press and Leger Marketing Report. Montreal: Leger Marketing.
24
World Health Organization. (2001). Vaccines: The History of Vaccination. www.who.int/vaccinesaccess/Vaccines/vaccinesindex.html.
25
World Health Organization. (2001). WHO Fact Sheet on Smallpox.
www.who.int/emc/diseases/smallpox/factsheet.html.
1
74
5. PUBLIC HEALTH: ON GUARD YEAR AFTER YEAR
26
Data supplied by Communicable Disease Epidemiology Services, British Columbia Centre for
Disease Control. Special request, September 2001.
27
American Academy of Pediatrics, Committee on Infectious Disease. (2000). Varicella Vaccine
Update (RE9941). Pediatrics, 105(1), 136-141. www.aap.org/policy/re9941.html.
28
National Advisory Committee on Immunization. (2002). NACI Update to Statement on Varicella
Vaccine. Canadian Communicable Disease Report, 28, ACS-3.
www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/02vol28/28sup/acs3.html.
29
Coalition for the Canadian Public Health Association in consultation with the Coalition for the
Canadian Immunization Awareness Program and the Canadian Coalition for Influenza
Immunization. (2001). The Value of Immunization in the Future of Canada’s Health System.
Submission to the Commission on the Future of Health Care in Canada. Ottawa, Canada.
30
Bureau of HIV/AIDS, STD, and TB, Laboratory Centre for Disease Control, Health Canada.
(1999). Syphilis in Canada: Elimination on the Horizon? STD Epi Update, May. Ottawa: Health
Protection Branch-LCDC.
31
Bureau of HIV/AIDS, STD, and TB, Health Canada. (2002). Infectious Syphilis in Canada. Update
Series, February. Ottawa: Health Protection Branch-LCDC.
32
BC Centre for Disease Control. (2002, March 11). Public and Physicians Advised of Worsening
Syphilis Outbreak in BC. Public Health Advisory (News Release).
www.bccdc.org/cdcmain/cdcpdf/syphilis_news_release.pdf.
33
National Cancer Institute of Canada. (2002). Canadian Cancer Statistics 2002. Toronto: NCIC.
www.ncic.cancer.ca.
34
Canadian Cancer Society. (2001). 2001 Key Cancer Statistics.
www.cancer.ca/english/RS_CancerFacts2001.asp.
35
Kerlikowske K. (1997). Efficacy of screening mammography among women aged 40 to 49 years
and 50 to 69 years: Comparison of relative and absolute benefit. Journal of the National Cancer
Institute. Monographs, 22, 79-86.
36
Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. (1993). Report of the international workshop
on screening for breast cancer. Journal of the National Cancer Institute, 85(20), 1644-1656.
37
Nystrom L, Andersson I, Bjurstam N, Frisell J, Nordenskjoid B, Rutqvist LE. (2002). Long-term
effects of mammography screening: Updated overview of the Swedish randomised trials. The
Lancet, 359(9310), 909-919.
38
Olsen O, Gøtzsche PC. (2001). Cochrane review on screening for breast cancer with
mammography. The Lancet, 358(9290), 1340-1342.
39
Kmietowicz Z. (2001). WHO insists screening can cut breast cancer rates. British Medical Journal,
324, 695.
40
National Cancer Institute. (2002). NCI Statement on Mammography Screening. National Institutes
of Health: NCI Press Office. www.newscenter.cancer.gov/pressreleases/mammstatement31jan02.html
41
Canadian Task Force on Preventive Health Care. (1998). Screening for Breast Cancer, 1988
Rewording. www.ctfphc.org/Tables/CH65tab2.htm.
42
Statistics Canada. (2002). Canadian Community Health Survey (special data run). Ottawa:
Statistics Canada.
43
Hertzman C. (1999). The biological embedding of early experience and its effects on health in
adulthood. Annals of the New York Academy of Science, 896, 85-95.
44
Health Canada, Human Resources Development Canada, Indian and Northern Affairs Canada.
(2001). The Federal/Provincial/Territorial Early Childhood Development Agreement: Report on
Government of Canada Activities and Expenditures 2000-2001. Ottawa: Minister of Public Works
and Government Services.
45
Sloan R, Cotroneo S. (2002). Partnering for social change: The “Back to Sleep” campaign.
Health Policy Research Bulletin, March 2002. Ottawa: Health Canada.
46
Tremblay MS, Katzmarzyk PT, Willms JD. (2002). Temporal trends in overweight and obesity in
Canada, 1981-1996. International Journal of Obesity, 26, 538-543.
47
Tremblay MS, Willms JD. (2000). Secular trends in the body mass index of Canadian children.
Canadian Medical Association Journal, 163(11), 1429-1433.
48
Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. (1999). The cost of obesity in Canada.
Canadian Medical Association Journal, 160, 483-488.
75
HEALTH CARE IN CANADA 2002
49
Craig CL, Cameron C, Russell SJ, Beaulieu A. (2001). Increasing Physical Activity: Supporting
Children’s Participation. Ottawa: Canadian Fitness and Lifestyle Research Institute.
50
Narayan KM, Bowman B, Engelgau M. (2001). Prevention of type 2 diabetes. British Medical
Journal, 323, 63.
51
Campbell K, Waters E, O’Meara S, Summerbell C. (2002). Interventions for preventing obesity in
Children. The Cochrane Library. Oxford: Update Software.
52
Silagy C, Lancaster T, Stead L, Mant D, Fowler G. (2001). Nicotine replacement therapy for
smoking cessation. Cochrane Database System Review, 3, CD000146.
53
Solberg L, Boyle R, Davidson G, Magnan S, Carlson C, Aslesci N. (2001) Aids to quitting tobacco
use: How important are they outside controlled trials? Preventive Medicine, 33, 53-58.
54
Health Canada. (2001). HIV/AIDS EpiUpdate: HIV/AIDS Among Injecting Drug Users in Canada.
Bureau of HIV/AIDS, STD, and TB. www.hc-sc.gc.ca/hpb/lcdc/bah/epi/idus_e.html.
55
Single E. (2001). Harm Reduction as the Basis for Hepatitis C Policy and Programming. First
Canadian Conference on Hepatitis C. Montreal, Canada, May 4th, 2001.
56
Health Canada. (2001). HIV/AIDS EpiUpdate: Risk Behaviours Among Injecting Drug Users in
Canada. Bureau of HIV/AIDS, STD, and TB. www.hc-sc.gc.ca/hpb/lcdc/bah/epi/drugr_e.html.
57
Guydish J, Bucardo J, Young M, Woods W, Grinstead O, Clark W. (1993). Evaluating needle
exchange: Are there negative effects? AIDS, 7, 871-876.
58
Watters JK, Estilo MJ, Clark GL, Lorvic J. (1994). Syringe and needle exchange as HIV/AIDS
prevention for injection drug users. Journal of the American Medical Association, 271(2), 115-120.
59
Gold M, Gafni A, Nelligan P, Millson P. (1997). Needle exchange programs: An economic
evaluation of a local experience. Canadian Medical Association Journal 157(3), 255-262.
60
Jacobs P, Calder P, Taylor M, Houseton S, Saunders LD, Albert T. (1999). Cost effectiveness of
streetworks’ needle exchange program of Edmonton. Canadian Journal of Public Health, 90(3),
168-171.
61
Monterroso ER, Hamburger ME, Vlahov D, Des Jarlais DC, Ouellet LJ, Altice FL, Byers RH, Kerndt
PR, Watters JK, Bowser BJ, Fernando MD, Holmberg SD. (2000). Prevention of HIV infection in
street-recruited injection drug users. Journal of Acquired Immune Deficiency Syndrome, 25, 63-70.
62
Gibson DR, Flynn NM, Perales D. (2001). Effectiveness of syringe exchange programs in reducing
HIV risk behavior and HIV seroconversion among injecting drug users. AIDS, 15, 1329-1341.
63
Advisory Committee on Population Health. (2001). Survey of Public Health Capacity in Canada,
Highlights. Report to the Federal, Provincial and Territorial Deputy Ministers of Health. Ottawa:
ACPH.
64
Emergency Preparedness Canada. (2001). Policy–How the System Works.
www.epc-pcc.gc.ca/home/index_e.html.
65
Health Canada. (2001, October 18). New Health Security Initiatives to Protect Canadians. News
release. www.hc-sc.gc.ca/english/media/releases/2001/2001_110e.htm.
66
Department Of National Defence. (2002, January 28). Defence R&D Canada to Coordinate $170
Million Fund to Improve Canada’s Response to Terrorist Threats. News Release NR-02.004.
76
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
6. Medicating Illness: Drug Use
and Cost in Canada
Caffeine, cannabis, codeine, COX-2 inhibitors—the range of drugs in use today
is varied and complex. Some affect the way we feel or think; others affect different
organ systems or very specific parts of the body. How we obtain drugs, as well as
how (and how much) we pay for them, varies almost as much as the effects that
different drugs can have on our bodies. This chapter focuses on the regulation,
use, and cost of prescription and non-prescription drugs across the country.
The World of Pharmaceuticals:
Regulating Drugs
Prescription and over-the-counter drugs help Canadians in many ways. They
can save lives, reduce the need for surgery, and allow us to maintain or improve
our quality of life.1 In some cases—such as antibiotics and insulin—new drugs
revolutionized the treatment of a disease. But many medications in use today are
“halfway technologies”. They alleviate symptoms but do not cure or prevent the
underlying condition.2
While many medications offer significant benefits, using drugs inappropriately
can lead to health risks and costs. For example, drugs can have serious side
effects and some medications are harmful when combined with other drugs or
natural products. In addition, drugs are sometimes prescribed for problems better
managed in other ways.3 And new more expensive drugs are sometimes used in
situations where older less expensive products would be equally effective. In
addition, mistakes can occur when drugs are prescribed or taken. Some people
also abuse or misuse medications. In a recent study in Atlantic Canada, for
instance, 15% of adolescents who had been prescribed stimulants told researchers
that they had given their drugs to others; 7% reported having sold them.4
Understanding and balancing the risks and benefits of drugs is not a new
challenge. Canadian governments have regulated drugs for medicinal use for
nearly a century. Parliament passed the Proprietary or Patent Medicine Act in
1908. It was a response to concerns about the potential health hazards posed by
many patent medicines. This law barred certain ingredients, such as cocaine and
alcohol (above set limits), from patent medicines. It also required that the
ingredients of the medicine be clearly labeled on the outside of the container.5
Today, the Food and Drugs Act regulates all products marketed to treat or
prevent diseases or symptoms. It covers the labeling, importing, processing,
advertising, and sale of medications.6 Under this law, Canadians must generally
HEALTH CARE IN CANADA 2002
obtain some drugs—such as antibiotics,
narcotic pain relievers, and sleeping
pills—from a licensed pharmacist with a
doctor’s prescription. Others, such as
aspirin and cold remedies, can be bought
over-the-counter.
Herbal remedies, vitamin and mineral
supplements, traditional Chinese and
Ayurvedic medicines, and other natural
health products are also generally available
without prescriptions. Health Canada
created a new Natural Health Products
Directorate in 1999. Its goal is to develop a
regulatory framework for these products,
including regulations for their licensing,
production, marketing, and labeling.7
Marijuana: Street Drug or
Medication?
With a change to the Narcotic Control Regulations,
the medical use of marijuana became legal in
Canada on July 30th, 2001. As a result, in cases where
the medical benefit is expected to outweigh the risks,
people with a serious and/or life-threatening illness
may now be allowed to use the drug.8 Patients must
apply to Health Canada for permission to use
marijuana, and their doctor must support their
application in writing.9 Health Canada granted 653
exemptions before this change; 145 new
authorizations have been granted since the new
regulations came into effect.10
How New Drugs are Born,
Developed, and Approved
There were almost 22,000 drug products
on Health Canada’s list of drugs approved
for human use in 2000.11 Not counting
biologic drug products (e.g. viral and
bacterial vaccines) and controlled
substances (e.g. heroin), about 5,200 were
prescription drugs.
Adding new drugs to this list is a complex
process,12,13 starting with basic research.
This step includes identifying new biological
processes, isolating and purifying the
original chemical or biological substance,
and testing the drug on animals.
78
Suppose this “pre-clinical” testing
confirms that the substance passes toxicity
testing and does what it is supposed to do.
The manufacturer can then ask Health
Canada for permission to conduct a clinical
trial. Clinical trials test whether a drug is
safe and effective in humans. They typically
use protocols designed to ensure sound
ethical, clinical, and analytical practices.
When clinical trials are complete, the
manufacturer can file a New Drug
Submission with Health Canada. This
submission outlines what is known about
the safety, efficacy, and quality of the drug.
It also describes the results of pre-clinical
studies and clinical trials, as well as the
drug’s production, packaging, labeling,
therapeutic claims, and adverse effects.
Teams of pharmaceutical and medical
scientists from Health Canada, as well as
external consultants and advisory
committees, review new drug submissions.
They evaluate the drug’s potential benefits
and risks. Health Canada also reviews the
information that the submission’s sponsor
plans to provide to health professionals
and consumers.
If the submission is approved, Health
Canada then issues a Notice of
Compliance and assigns a Drug
Identification Number. This permits the
sponsor to market the drug in Canada. If
the submission is not approved, the
manufacturer can choose to supply
additional information, re-submit with
more information at a later date, or
appeal the government’s decision.
The length of this process varies from
drug to drug and year to year. Some
scientists argue that the process needs to
be thorough enough to properly evaluate
the safety and therapeutic value of new
drugs and what benefits they do, and do
not, provide. Others are concerned that it
should minimize unnecessary delays in
approving drugs that promise major
advances over existing medications.14,15
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
Watching the Clock: Drug Approval
Times Compare
63
Shown below are median approval times (from the date an
application was submitted to the date the product was
approved) for new drugs approved in at least one of five
countries between 1992 and 1998. The median approval time
of the 26 drugs that were approved in Canada in 1998 was
17 months. That’s about the same as in Australia, and
somewhat longer than in Sweden, the United Kingdom, and
the United States. Special programs exist to provide for faster
approvals (e.g. for life-threatening conditions where there are
not already many effective treatments on the market) and to
allow for special access to drugs prior to approval (e.g. where
no other therapy is available or already-approved drugs have
not worked).
45
40
Median approval time (months)
35
30
25
20
15
10
5
0
1992
1993
1994
Canada
1995
Australia
Sweden
1996
UK
1997
1998
Thalidomide: A Case of
Unanticipated Effects
Thalidomide was originally developed to treat
allergies. Testing showed that it was not an effective
antihistamine. But it did relieve morning sickness in
the early stages of pregnancy and induce sleep.
Found to be non-toxic in testing on animals, drug
companies widely marketed thalidomide throughout
the world in the late 1950s. By 1961, they had
withdrawn it from most markets.16
What happened? Experts found that babies born
to pregnant women who took the drug were more
likely to have severe birth defects, such as malformed
limbs and internal organs.16 In Canada, about 115
children were affected.17 That’s a lower number than
in many parts of Europe, Australia, South America,
and elsewhere, probably because approval of the
drug took longer in Canada. A Canadian, Dr. Frances
Kelsey, also played a major role in preventing
approval of thalidomide in the United States.18
In 1963, the government tightened safety
standards and information requirements in an
attempt to prevent similar problems in the future. But
the thalidomide story is not over.17 Researchers have
recently found new uses for the drug in the treatment
of leprosy and other autoimmune and inflammatory
disorders, including HIV/AIDS.16
US
Source: Rawson NSB. (2000).Time required for approval of new drugs in Canada,
Australia, Sweden, the United Kingdom, and the United States—in 1996–1998.
Reprinted from, Canadian Medical Association Journal, 162(4), 501-504,
by permission of the publisher ©2000 CMA.
Watching for Problems
after Approval
Tragedies make for long memories. The
world’s experience with drugs like
thalidomide continues to remind us that
ongoing monitoring of the effects of drugs
is important.
In some cases, testing does not identify
all the problems (or all indications for
which they are effective) before drugs are
approved for use. Problems can occur
because groups for whom safety and
efficacy were not determined in the original
clinical trials take the drug, because the
drug may interact with other drugs or
substances that patients are taking, or for
many other reasons.
Health Canada does not generally
require specific long-term studies to detect
harmful effects of drugs. Instead, ‘postmarketing surveillance’ of drugs—
gathering information about potential
problems after drug approval—usually
takes place in other ways. For example,
under the Food and Drug Act, drug
manufacturers must tell Health Canada
about any serious adverse drug reactions
that they become aware of.19,20
Health Canada also has “passive” systems
to monitor drugs. They encourage, but do
not require, physicians, pharmacists, and
other health professionals to report major
or minor undesirable effects experienced
by consumers.19
What happens when problems are
found? The government directs most
information about suspected or proven
adverse drug reactions to physicians and
other health professionals.19 For example,
79
HEALTH CARE IN CANADA 2002
Health Canada publishes safety alerts
about medications in the Canadian
Adverse Drug Reaction Newsletter.
Increasingly, consumers are also using
the Internet and other means to access
information about the adverse effects of
drugs.21 For example, the Canadian
Diabetes Association’s Web site discusses
issues surrounding animal and human
insulin.22 Using recombinant DNA
technology, scientists were able to produce
a new form of insulin that is chemically
identical to insulin produced by the human
pancreas.23 This ‘human’ insulin therefore
reduces the chance of allergic reactions
that some people experience when using
insulin made from animal sources. As use
of human insulin became widespread in
the 1990s, some people reported
problems identifying their hypoglycemia
(low blood sugar) when they switched from
animal insulin to the new product.24 In a
recent review of the evidence, researchers
concluded that studies have failed to show
that treatment with human insulin per se
affects the frequency or awareness of
hypoglycemia.25 Today, people who require
insulin are usually started on human insulin
and thus avoid having to switch from one
form to the other. Because some
uncertainty about safety remains, care
providers closely monitor those who switch
from animal to human insulin, and insulin
made from animal sources continues to be
available.22
Why Do Some Drugs Require
a Prescription?
Over-the-counter drugs such as aspirin are
legally available without a prescription but
may be prescribed. Usually, consumers pay
directly for over-the-counter drugs, although,
when prescribed, they may sometimes be
covered by public and private drug plans.
Other drugs require a prescription. Private
insurance plans or public programs often
cover the cost of these drugs.
80
Drugs can be two-edged swords. Taken
for the right reasons and in the proper
dosage, they can be very helpful, even lifesaving. But often, it requires a health
professional’s extensive knowledge and
expertise to select the drug(s) best suited to
the condition(s) of the patient; taking drugs
in combination may cause harm; and
effectiveness is dependent on taking the
right drugs for the right length of time. As
a result, manufacturers or others can
request that a particular drug be available
over-the-counter or require a prescription.
Ultimately, Health Canada makes the
decision. Whether a particular drug
requires a prescription can vary from
country to country.
According to the World Health
Organization (WHO), there are pros and
cons to having medications available to
consumers without a prescription.26 WHO
suggests that self-medication may reduce
pressures on the health care system. But
they say that it may also lead to delays in
seeking needed care. In addition,
consumers may think that drugs available
without a prescription are harmless. WHO
argues that this may result in excessive and
potentially dangerous levels of use.
Who Takes What
Medication?
Millions of Canadians take drugs daily.
Most fill at least one prescription each year.
The 1998/1999 National Population
Health Survey asked Canadians aged 12
and over about their medication use.
Nearly eight in ten respondents (78%) said
that they had used one or more prescribed
or over-the-counter medications in the last
month. Women and older Canadians were
more likely to report using medications
than others were. Low-income Canadians
also tended to report higher use of many
medications. Painkillers and allergy
medication were exceptions.
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
Who Is Taking Medications?
64
Most Canadians report having taken at least one prescribed or
non-prescribed drug in the last month. Many report using
multiple drugs. The graph below shows the percent of all
Canadians aged 12 and older (top 3 bars) and seniors (bottom
3 bars) who reported using different numbers of prescribed and
non-prescribed drugs in the last month. Multiple medication use
is more common for seniors, and the proportion of seniors that
report using five or more drugs is increasing.
1998/1999
Canadians
Aged 12
and older
Painkillers—ranging from aspirin to
morphine—are among the most commonly
used drugs. About 65% of Canadians said
they had taken painkillers in the last month.
Other commonly used drugs include heart
medications (13%), stomach remedies
(13%), penicillin or other antibiotics (8%),
sleeping pills and tranquilizers (5%), and
antidepressants (4%).
Top Selling Drugs Around the World
1996/1997
66
Given the different names under which they are sold, doses
used, prices paid, and regulations in place, international
comparisons of drug use and sales are difficult. The chart
below compares the top 7 selling groups of drugs in Canada’s
retail pharmacies with their ranks in 8 other countries in 2001.
1994/1995
1998/1999
Seniors
1996/1997
1994/1995
0%
20%
40%
60%
80%
100%
% of Respondents
No drugs
1 drug
2 drugs
3 drugs
4 drugs
5 or more drugs
** Includes pain killers
† Includes sales through mail order channels
‡ Includes sales to hospitals
Source: National Population Health Survey, Statistics Canada
Trends in the Use of Different Drugs
65
Canadians’ use of different types of drugs has changed over
time. The graph below shows the percentage aged 12 and
older who reported taking different types of commonly-used
prescribed or non-prescribed drugs in the past month. Rates
are not adjusted for differences in the age and sex composition
of the population over time.
70
1994/1995
% of Respondents
60
1996/1997
1998/1999
50
40
30
20
10
0
Insulin and
diabetes
Antidepressants
Sleeping pills Penicillin and
other
and
antibiotics
tranquilizers
Gastrointestinal
disorders
Heart
medication
Pain killers
Types of medications
Source: National Population Health Survey, Statistics Canada
Source: IMS Health, 2001.
Old or New? Choices
to be Made When
Prescribing
New drugs are introduced each year. In
some cases, they are better than older
drugs, perhaps because they are more
effective, are easier to use, or have fewer
side effects. For example, recent advances
offer new ways of treating peptic ulcer
disease, high blood pressure, AIDS, erectile
dysfunction, depression, and other
conditions.1 But newer drugs may also be
more expensive than older ones and are
not always the best choice for particular
patients. For example, a study showed that
in Manitoba between 1995 and 1998,27
81
HEALTH CARE IN CANADA 2002
the number of prescriptions for newer
broad-spectrum antibiotics grew relative
to prescriptions for older antibiotics. The
increase occurred even though broadspectrum antibiotics are more expensive and
their widespread use may increase the risks
of antibiotic resistant organisms.27
Public Spending: New Drugs Take Over
67
By 1998/1999, provincial drug plans in Ontario,
Saskatchewan, Alberta, and British Columbia were paying
more, in total, for drugs introduced after 1991/1992 (“newer”
drugs) than for older (“existing”) drugs. Between 1993/1994
and 1998/1999, total drug expenditures climbed, while
spending on existing drugs decreased.
2,500
Total spending (millions of dollars)
2,000
1,500
1,000
500
0
1993/1994
1994/1995
1995/1996
Total
1996/1997
New
1997/1998
1998/1999
Existing
Source: Federal/Provincial/Territorial Working Group on Drug Prices. (2000). Cost Driver Analysis
of Provincial Drug Plans, Ontario, Saskatchewan, Alberta, British Columbia.
www.hc-sc.gc.ca/english/feature/fpt2001/pdf/cost_drivers/british_columbia_cost_driver.pdf
www.hc-sc.gc.ca/english/feature/fpt2001/pdf/cost_drivers/alberta_cost_driver.pdf
www.hc-sc.gc.ca/english/feature/fpt2001/pdf/cost_drivers/saskatchewan_cost_driver.pdf
www.hc-sc.gc.ca/english/feature/fpt2001/pdf/cost_drivers/ontario_cost_driver.pdf
Use of New Heartburn Medications
First introduced in 1989, proton pump inhibitors (PPIs) reduce the
amount of acid in the stomach. They are used to treat peptic ulcer disease
and gastroesophageal reflux, a serious disorder that causes persistent
heartburn and abdominal pain.
These symptoms are common and may or may not be associated with a
serious disorder. Older, less expensive, drugs that reduce stomach acid and
relieve heartburn are also available. As a result, some argue that overuse
of PPIs to treat symptoms associated with minor problems is unnecessarily
costly.28 Some jurisdictions restrict access to these drugs through public
drug plans. For instance, Ontario has a “step-up” policy which lists PPIs as
“limited use” drugs. Patients will only be reimbursed if they have a
confirmed serious disorder or after an unsuccessful 8-week trial of a less
expensive medication.29
The Terms of Patent
In Canada, many new drugs are
eligible for patent protection. The holder
of the patent has the exclusive right to
make, sell, or otherwise exploit the
invention for a limited period of time.
Most (about 96% in 2000) patented drug
products require a prescription.30
Canada has periodically changed the
duration of drug patents and the
conditions attached to them. For
example, Bill C-22—passed in 1987—
extended the minimum term from 17 to
20 years for new patents. A recent
amendment to the Bill extended the
minimum 20-year standard to any nonexpired patent that had a term of less
than 20 years.31
At the same time as Bill C-22 was
passed, the government created the
Patented Medicine Prices Review Board
(PMPRB). The Board aims to ensure that
prices charged for patented medicines
are not excessive. Among other things,
PMPRB regulates the prices set by
manufacturers for patented prescription
and non-prescription drugs. They do not,
however, control prices charged by
wholesalers, retailers, or pharmacists’
fees. Nor do they regulate the prices of
drugs that are not under patent.32
Under the Patent Act, prices for existing
drugs cannot increase more than the
consumer price index each year. Also, the
cost of new patented drugs must fall
within the range of existing drugs to treat
the same condition. Costs for
breakthrough drugs—those that offer a
substantial improvement over existing
drugs—cannot be set higher than the
median cost in seven countries used for
comparison.32 *
* For these comparisons, the PMPRB uses a method different from the method in the other six countries to calculate drug
prices in the United States because many buyers in the United States are able to negotiate confidential discounts.30
82
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
Overall, patented medicine prices have
increased by less than the consumer price
index each year since 1988, except 1992,
according to PMPRB.30
What about drugs that are not under
patent? In 1999, governments across the
Ups and Downs in the Prices
of Patented Medicines
5.0
4.1
2.8
1.9
2.1
1.0
0.0
0.2
0.1
0.1
-1.0
-2.0
-3.0
69
The value of sales of patented drugs has grown in recent
years, while sales of non-patented and generic drugs have
stayed relatively stable. The chart below shows total sales of
generic, non-patented brand-name, and patented drugs in
billions of dollars between 1990 and 2000. As of 1999,
figures include sales of drugs for human use only. Figures are
not adjusted for inflation.
0.4
12
-0.1
10
-0.7
-1.9
-2.2
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Note: beginning in 1999, the PMPI reflects changes in the prices of patented drugs for
human use only.
Source: Patented Medicines Prices Review Board, Annual Report, 2000.
country conducted a study of 72 topselling non-patented drugs with a single
Canadian source.33 Researchers
compared prices for these drugs paid by
government drug plans in Ontario and
British Columbia with those in the seven
countries used by PMPRB to compare
prices of patented drugs. They found that
the median prices of the drugs in Canada
were, on average, 30% higher than those
in the other countries. But our prices were
Total sales (billions of dollars)
% change in index from previous year
2.0
In 2000, manufacturers sold about $6.3 billion of patented
medicines in Canada, according to the Patented Medicine Price
Review Board (PMPRB).30 That’s just under two-thirds (63%) of
total drug sales across the country, up from 43.3% in 1995.
PMPRB suggests that, in part, the long-term effects of extended
patent protection may explain this increase.
Changing Shares of Sales
3.9
3.0
Dividing the Market: Brand
Name and Generic Sales
68
The graph below shows the average change in the average
(ex-factory) price of patented drugs sold in Canada between
1988 and 2000. After several years of increases, average
prices for patented drugs decreased beginning in 1994. They
began to increase slightly beginning in 1999.
4.0
generally lower than those in the United
States. Consumers south of the border
paid 96% more, on average, than
Canadians for the products included in
the comparisons.
8
6.3
6
4
1.6
2
1.8
0
1.9
2.1
2.1
2.3
2.4
2.6
2.9
2.8
5.4
4.3
3
3.7
2.9
2.6
2.4
2.6
2.7
2.7
2.8
0.3
0.4
0.4
0.4
0.6
0.6
0.7
0.7
0.8
0.8
0.9
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Generic
Non-patented Brand Name
Patented
Source: Patented Medicines Prices Review Board, Annual Report, 2000.
Most of the remaining sales (28%) were non-patented brandname drugs sold by companies that also sell patented drugs.
“Generic” drugs—copies of drugs for which the original patent(s)
have expired—accounted for about 9% of sales in 2000. These
drugs are often marketed by more than one manufacturer.
83
HEALTH CARE IN CANADA 2002
How Much are We
Spending?
Retail drug sales became the second
largest category of total health spending
(after hospitals) in 1997, overtaking
physician services. In total, Canadians are
expected to have spent over $15.5 billion on
drugs in 2001, up 8.6% from the previous
year.34 That is just over $500 per person.
In Canada, both the public and private
sectors pay part of the drug bill. Public
sector payers include governments,
Workers’ Compensation Boards, and
other social security schemes.
The federal government pays for
prescribed drugs for the military, the Royal
Canadian Mounted Police, veterans,
inmates in federal jails, and Status
Indians and Inuit when these costs are not
covered by other insurance plans.32
Provincial/territorial governments pay for
drugs given to patients in hospitals across
the country.
Where Canada Stands
Canada spends more per person on drugs than most other countries. As of 1997, only four of the 25 OECD countries who reported spending on drugs
dispensed to outpatients* paid more per person than Canada (figures were adjusted for differences in purchasing power between countries).35 We spent
less per person than France, the United States, Japan, and Belgium.
There are many reasons why spending on drugs or on health care varies from country to country. One possible explanation is differences in drug
prices. Each year, the
Patented Medicine Prices
Drug Prices and the Share of Health Care Spending
70
Review Board compares
The cost for a particular basket of drugs can be different in different countries. The average foreign to
Canadian prices for drugs
Canadian price ratio is an index of patented drug prices in Canada and other countries. In countries
under patent to those in
where the same basket of drugs would be more expensive than in Canada (like the US), the ratio is
seven other countries. In this
higher than 100. In countries where the same basket of drugs would be less expensive (like Italy) the
group, countries with higher
ratio is lower than 100.
drug prices in 1998 tended
to spend more in total
For the most part, where the index is relatively high, drugs cost more and more money is spent per
capita on health (see left below). But higher drug costs don’t necessarily mean higher drug spending
(public and private) on
(see right below) Note that only a few countries are shown on these graphs, and that each country may
health care per person (see
have a different way of calculating the percent of total health spending for prescription drugs.
left graph below). But they
Comparisons should be interpreted cautiously.
also tended to spend a
smaller share of this total
Higher 180
Higher 180
price
price
amount on drugs (see right
U.S.
ratio 160
ratio 160
U.S.
graph below).
Both graphs show an
140
140
index
of patented drug
Switzerland
Switzerland
120
120
prices
in Canada compared
Sweden Germany
U.K.
U.K.
W
W
100
100
with
the
other countries. A
France CANADA
CANADA
France
Italy
value
of
100
means that,
80
80
overall, prices for the basket
60
60
of drugs considered were the
same as those in Canada.
40
40
The lines across the charts
20
20
are at this level. Countries
Lower
Lower
price
price
0
0
with points above this line
ratio
ratio
$0
$1,000
$2,000
$3,000
$4,000
$5,000
0
2
4
6
8
10
12
14
16
tended to have higher prices
Total per capita health spending
% of total health spending for prescription drugs
than Canada. Those below
Lower
Higher
Smaller
Larger
spending
spending
percent
percent
had lower prices.
Notes: Data are from 1998.
Per capita spending estimates are adjusted for differences in purchasing power between countries.
Spending on prescription drugs in UK from 1997 (not available for 1998).
Source: OECD Health Data, 2001; Patented Medicine Prices Review Board, 1998
*
Includes spending on “medical non-durables”, such as orthopaedic and surgical appliances,
since these expenditures were not reported separately by many countries.
84
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
They also have a variety of programs
that cover parts of the total drug bill. In
addition, income-related tax credits partly
offset a range of medical expenses,
including prescription drugs.
Individual Canadians also pay some
drug costs out of their own pockets.
Private insurance, often provided through
the workplace, is the other major private
sector payer.
The public/private split of drug
spending is gradually changing. In 2001,
61% of retail drug sales (about $300 per
person) were paid for by private sources.
That compares with 85% in 1975.
Between 2000 and 2001, CIHI estimates
that public sector spending grew more
than four times faster (over 16%) than
private sector spending (just under 3%).
Public versus Private Drug Spending
71
Public and private per capita spending on retail drugs,
unadjusted for inflation, has risen steadily since 1975. Between
2000 and 2001, public sector drug spending is estimated to
have increased by over 16%, compared to just under 3% for
private sector spending.
$350
$300
$ per capita
$250
$200
$150
$100
$50
Private
2001f
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
$0
Public
Note: Open symbols are forecast figures.
Source: National Health Expenditure Database, CIHI.
Within the overall trend, the mix of drug
spending continues to vary significantly
across the country. In 2001, the public share
ranged from 22% in Prince Edward Island to
48% in the Yukon Territories. In part, this
may be explained by variations in private
and government insurance coverage.
Drug Spending From Coast to Coast
72
In 2001, public and private sector payers in Canada spent an
average of just over $500 per person on retail drug sales. The
private share varied from $150 per person in Nunavut to $399
in Prince Edward Island.
$194
$305
CAN
$257
$278
YT
$113
$399
$130
$150
$132
$151
PE
NU
NF
NT
$174
$255
BC
$159
$271
AB
$152
$269
SK
$144
$315
$154
$268
MB
$203
$351
$235
$274
QC
ON
NB
$122
$325
Public
Private
NS
$164
$357
Source: National Health Expenditure Database, CIHI.
Whose Drug Costs are
Insured?
Three-quarters (75%) of Canadians aged
12 and older reported some public or
private insurance coverage (with varying
levels of deductibles) for prescription drugs
in 1998/1999. Young adults and low
income Canadians were least likely to say
that they were insured. In part, this likely
reflects the fact that private insurance is
often a benefit of employment, covering
employees and their dependents.
Who Has Insurance Coverage?
73
In 1998/1999, Canadians with the lowest levels of education
and income were least likely to report having insurance for
prescription drugs than those with the highest levels. The tables
below show the proportion of Canadians aged 12 and older
by education and income levels who reported having insurance
for drugs in that year.
Source: National Population Health Survey, Statistics Canada
85
HEALTH CARE IN CANADA 2002
Each province and territory has
developed its own publicly funded drug
plan(s). As a result, families with similar
incomes and medical needs may receive
very different government-funded benefits
depending on where they live.
Persons receiving social assistance are
covered in all provinces and territories, but
program benefits vary. Most government
plans also cover seniors (although
coverage is based on income in some
provinces). Some government drug plans
also cover persons with specific diseases—
such as HIV/AIDS, cancer, and diabetes—
who often require expensive drug therapy.
The diseases that qualify for coverage vary
across the country.
Most public plans require clients to share
part of the cost of their drugs through
deductibles and/or co-payments. These
requirements differ across the country. For
example, public drug plans cover all
residents of Saskatchewan, British
Columbia, and Manitoba, but residents
must pay relatively high deductibles.
Likewise, all residents without private
insurance are covered under public plans
in Quebec, but most Quebec residents
must pay a monthly deductible.
Which drugs are covered by public drug
plans also varies.36,37 Some drugs appear
on all provincial/territorial “formularies”—
lists of drugs eligible for reimbursement.
Others are covered only in selected
jurisdictions. The conditions under which
particular drugs are covered may also vary.
Many factors influence coverage
decisions for drugs. For example, groups
like the Canadian Council on Health
Technology Assessment aim to help
governments weigh the potential costs and
value of new technologies, including new
drugs. They use sophisticated guidelines
and tools to compare the dollar costs,
Who is Eligible for Coverage?
74
Coverage of provincial/territorial drug plans varies across the country. The chart below shows that
eligible groups differ. Co-payments and deductibles also vary. A co-payment is the share of the cost
of a prescription (Rx) that a patient must pay. For example, they may be required to pay $4.00 per
prescription or 20% of the cost for each prescription. A deductible is an amount that a patient must
pay, often on a yearly basis, before insurance payments begin. It is usually subtracted from the
amount that patients are reimbursed on their first claims in each calendar year.
Notes: Information for Nunavut is not included in this table.
* Guaranteed Income Supplement
**Available for all Ontario residents who have high drug costs in relation to income.
Source: Compiled by CIHI.
86
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
efficacy of treatment, potential number and
quality of life years gained, and other
factors for new drugs with those for other
ways of treating a particular condition. In
practice, however, a recent review
highlighted the importance of factors
beyond cost-effectiveness in the decisionmaking process.37
Which Drugs are Covered Depends
on Where You Live
More than 2 million Canadians have diabetes. Although diet and
exercise are the mainstay of therapy, some people with diabetes require
specific medication and medical supplies to manage their illness. For
those with private insurance, these drugs and supplies may be covered
under supplementary health plans. For those without private insurance,
most provincial/territorial drug plans cover some of the costs for
diabetes drugs, although the extent of the coverage varies from
province to province. Some provinces also provide additional coverage
for people with diabetes and other conditions for which drug costs may
be high. But there are variations in which drugs are covered.
To illustrate the differences, the Canadian Diabetes Association, in
partnership with the Association Diabète Québec, recently
summarized which provinces cover which diabetes drugs under the
provincial drug plan.
What’s on Whose Formulary
75
Provinces/territories develop lists of drugs, known as
formularies, that their plans cover. Some drugs are covered in
all jurisdictions. Others vary. In some cases, drugs have
“restricted” status, limiting coverage to particular types of
patients or situations. The chart below shows which provinces
typically covered insulin and nine specific diabetes drugs on
their formularies. A check mark indicates coverage, “X”
indicates no coverage, “R” indicates restricted status.
Source: Diabetes Report Card 2001, Canadian Diabetes Association,
www.diabetes.ca/news/reportcard/cda_report_card.pdf, updated by CIHI
based on information provided by provinces.
*as of September 2001, more recent update not available
Why is Drug Spending
Rising?
Canada’s drug bill has been steadily
rising in recent years. In 2001, we are
forecast to have spent more than twice as
much per person on retail drug sales than
they did in 1990 (unadjusted for inflation).
Researchers agree that this increase
reflects many different trends. For example,
the PMPRB recently compiled the following
list of factors affecting drug spending:30
• Changes in the size of the total
population
• Changes in population demographics
and health status
• Changes in the unit prices of patented
and non-patented drugs
• Changes in retail and wholesale markups and professional fees
• Changes in the prescribing habits of
physicians (e.g. from older, less
expensive medication to newer, relatively
more expensive medications to treat the
same underlying condition)
• Changes in utilization of drugs on a per
patient basis (e.g. more medications per
patient per year)
• Trends towards using drug therapies
instead of other treatments (e.g. as
alternatives to surgery in some cases)
• Emergence of new diseases for which
there are drug treatments
• Persistence of old diseases for which
there are now drug treatments (where
none existed before or where they can be
better treated with new drugs).
Many studies are underway to determine
which factors matter most and how they
affect overall spending on drugs. For
example, Steve Morgan at the University of
British Columbia recently studied 64
million prescriptions dispensed to seniors in
British Columbia between 1987 and
1999.40 These prescriptions were covered
by the province’s Pharmacare plan A.
87
HEALTH CARE IN CANADA 2002
Over this period, the average number of
prescriptions per person grew by 15%.
Drug costs per person, however, jumped
almost 150% ($192 to $479), even though
there was relatively little price inflation over
this period. Increased use of newer drugs
explains part of this growth. Drugs that
had existed pre-1986 still accounted for
over half (59%) of all prescriptions in
1999, but they represented only 22% of
spending in that year.
What Explains BC’s Rising Drug Bill
76
In another study of prescriptions dispensed to seniors under
British Columbia’s Pharmacare Plan, Steve Morgan looked at
what explained the jump in average drug costs per person
between 1985 and 1999. He found that three major factors
drove increases over this period. Their relative importance is
shown below.
22¢: Higher prices for individual
products (partially offset by the
substitution of lower-cost generic
products for brand name drugs)
38¢: Seniors had prescriptions from
more categories of drugs (e.g.
nonsteroidal anti-inflammatory agents
or benzodiazepines), on average
40¢: Different drugs were prescribed
within a category (e.g. switches of
drugs within a category, increased
doses, or additional prescriptions for
other drugs within the same category)
Source: Morgan S. (2002). Quantifying components of drug expenditure inflation: The British
Columbia Seniors’ Drug Benefit Program. Health Services Research (HSR), in print.
Another researcher with British
Columbia’s Pharmacare Program showed
that average costs of newly introduced
prescription drugs have increased over
time.41 He showed that the average cost of
prescriptions in British Columbia for drugs
that came on the market before 1986
increased from $17.15 in 1985 to $25.17
in 2000, generally in keeping with
inflation. The average cost of new drugs,
however, has increased steadily over time,
in excess of what would be expected on the
basis of inflation alone. New drugs
88
introduced between 1998 and 2000, for
example, cost, on average, $114.41 per
prescription in 2000.
Does Direct-to-Consumer
Advertising of Drugs
Matter?
Unlike in the United States and New Zealand, drug
companies are forbidden to market prescription drugs
directly to Canadian consumers.42 Ads that include the
drug’s name, price, and quantity and indirect ads are,
however, allowed. The latter include, for example, ads
whose primary purpose is not to promote drug sales,
that do not identify specific drugs, that offer disease
awareness or help-seeking messages, or that promote
a company rather than a specific drug.
Direct-to-consumer advertising of prescription
drugs (DTCA) is controversial.43 Proponents claim that
it may educate and empower consumers, improve
compliance with drug therapy, and promote earlier
use of drugs (possibly contributing to better health
and/or reduced hospitalization costs). Opponents
maintain that exposure to DTCA and the availability
of similar information on the Internet can contribute
to inappropriate prescribing, rising drug costs, and
potential harm to the patient and to the
doctor/patient relationship. Others argue that because
drugs are advertised on cable TV and the Internet, to
which Canadians have access, regulating DTCA is
increasingly difficult.
A recent study43 found that DTCA may have an
impact on consumer behavior, prescribing patterns,
and costs, even in Canada. The authors compared the
behaviour and opinions of 78 physicians and 1,431
patients in Sacramento and Vancouver. Most patients
in both centres (including 90% of those in Vancouver)
reported having seen prescription drug ads.
Nevertheless, Sacramento patients were more likely to
request one or more drugs during their consultations
(15.8% versus 9.0%), particularly advertised drugs
(7.3% versus 3.2%).
In most cases, physicians prescribed requested drugs
(79.6% in Sacramento compared with 62.6% in
Vancouver),43 even though they said that they would
not necessarily prescribe that drug to another patient
with the same complaint who had not requested the
drug by name.43 In 50% of cases where patients
requested an advertised drug, physicians reported
being ambivalent about the choice of treatment. That
compares with 12.4% of cases where prescriptions were
not requested by patients.
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
Information Gaps—Some Examples
What We Know
• Most Canadians use some form of prescription or non-prescription medication over
the course of a year.
• Public and private spending on drugs has increased every year since at least 1975
(unadjusted for inflation).
• Eligibility criteria, benefit levels, and coverage provided by provincial/territorial drug
programs vary.
What We Don’t Know
• What has been the total impact of extended patent protection on drug utilization,
costs, and patient outcomes?
• What strategies are most effective in controlling costs and increases in utilization,
while ensuring high quality patient care?
• Are the drivers of recent increases in spending on drugs the same across the
country?
• What approaches help patients and their caregivers to maximize the benefits of
medications while minimizing risks?
What’s Happening
• CIHI and the Canadian Institutes of Health Research (CIHR) are jointly funding
research to determine the extent of adverse events in Canadian hospitals—
including medication errors—and to explore the development of strategies to monitor
and reduce these events.
• CIHI and the Patented Medicine Prices Review Board (PMPRB) are working together to
develop a pan-Canadian prescription drug utilization information system.
• At their January 2002 conference, premiers agreed to start a common review
process for new drugs to be covered under provincial/territorial drug plans and to
work together to streamline the approval process for generic drugs.44
89
HEALTH CARE IN CANADA 2002
For More Information
Berndt ER. (2001).The U.S. pharmaceutical industry: Why major growth in times of cost
containment. Health Affairs, 20, 100-114.
2
Brown E. (1996). Halfway technologies. Physician Executive, 22(12), 44-45.
3
Tamblyn R. (1996). Medication use in seniors: Challenges and solutions. Thérapie, 51(3), 269-282.
4
Poulin C. (2001). Medical and nonmedical stimulant use among adolescents: From sanctioned to
unsanctioned use. Canadian Medical Association Journal, 165(8), 1039-1044.
5
Murray, GF. (1988). The road to regulation: Patent medicines in Canada in historical perspective.
In Blackwell JC and Erickson PG (Eds). Illicit Drugs in Canada, a Risky Business. Scarborough:
Nelson Canada.
6
Health Canada. (2000). Food and Drugs Act and Regulations Departmental Consolidation.
Ottawa: Health Canada.
7
Health Canada. (2002). Welcome to Natural Products Directorate.
www.hc-sc.gc.ca/hpb/onhp/welcome_e.html
8
Office of Controlled Substances, Health Canada. (April 7, 2001). Marihuana Medical Access
Regulations, Proposed Regulations, Regulatory Impact Analysis Statement.
www.hc-sc.gc.ca/hpb-dgps/therapeut/zfiles/english/schedule/gazette.i/marihuana_e.pdf
9
Health Canada, Office of Cannabis Medical Access. (2001). Medical Access to Marijuana - How
the Regulations Work. www.hc-sc.gc.ca/hecs-sesc/ocma/bckdr_1-0601.htm
10
Personal Communication. (2002). Office of Cannabis Medical Access, Health Canada.
11
Patented Medicine Prices Review Board. (2000). Annual Report 2000. www.pmprb-cepmb.gc.ca
12
Health Canada. (2001, March). Tough tests for drugs. Health!Canada Magazine.
www.hc-sc.gc.ca/english/magazine/2001_03/drugs.htm
13
Health Canada. (2001). How Drugs are Reviewed in Canada.
www.hc-sc.gc.ca/hpb-dgps/therapeut/zfiles/english/fact-sht/fact_drug_e.html
14
Lexchin J, Mintzes B. (2000). Drug approval times (letter). Canadian Medical Association Journal,
162, 1803-1804.
15
Rawson NSB. (2000). Drug approval times (letter). Canadian Medical Association Journal,
162, 1804.
16
Blakeslee D. (1998). Thalidomide. HIV/AIDS Resource Center, The Journal of the American
Medical Association. www.ama-assn.org/special/hiv/newsline/briefing/thalido.htm
17
The Canadian Encyclopedia. (2002). Pharmaceutical Industry. www.thecanadianencyclopedia.com
18
The Canadian Encyclopedia. (2002). Frances Oldham Kelsey. www.thecanadianencyclopedia.com
19
Health Canada, Therapeutic Products Directorate. (2001). Adverse Drug Reactions.
www.hc-sc.gc.ca/hpb-dgps/therapeut
20
Health Canada. (2001). Guidelines for Reporting Adverse Reactions to Marketed Drugs. Ottawa:
Health Canada, Therapeutic Products Directorate.
www.hc-sc.gc.ca/hpb-dgps/therapeut/zfiles/english/adr/industry-guidelines_e.pdf
21
Health Canada. (2000). The Product Monograph: Format, Content and Public Dissemination.
Proceedings from a Multi-Stakeholder Consultation Workshop, September 11-13, 2000. Ottawa:
Health Canada.
22
Canadian Diabetes Association. (2002). Information on Availability of Animal Insulin.
www.diabetes.ca/about_diabetes/animal_insulin.html
23
Reddy NR, Reddy IK. (2001). Insulin Formulations and Injection Devices: Current Status and Future
Trends. http://secure.1f.com/drug/ce/winter_2001/ce01_insulin_lesson.htm
24
Diabetes UK. (2000, July 11). Need for Animal Insulin. www.diabetes.org.uk/news/july00/animal.htm
25
Williams DR, Airey CM, Martin PG, Bennett CM, Spoor PA. (2000). Hypoglycaemia induced by
exogenous insulin-’human’ and animal insulin compared. Diabetic Medicine, 17, 416-432.
26
World Health Organization. (2000). The benefits and risks of self-medication. WHO Drug
Information, 14(1), 1-2.
27
Carrie AG, Metge CJ, Zhanel GC. (2000). Antibiotic use in a Canadian province, 1995-1998.
Annals of Pharmacotherapy, 34(4), 459-464.
1
90
6. MEDICATING ILLNESS: DRUG USE AND COST IN CANADA
28
Bashford JNR, Norwood J, Chapman SR. (1998). Why are patients prescribed proton pump
inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice
Research Database. British Medical Journal, 317, 452-456.
29
Mamdani MM, Tu K, Jaakkimainen L, Bica A, Hux J. (2001). Proton pump inhibitors: Compliance
with a mandated step-up program. Canadian Family Physician, 47, 531-535.
30
Patented Medicine Prices Review Board. (2000). Annual Report 2000. www.pmprb-cepmb.gc.ca
31
Industry Canada. (2001, July 12). News Release. Government of Canada brings Patent Act into
conformity with obligations under the World Trade Organization. www.ic.gc.ca.
32
Government of Canada. (1997). Review of the Patent Act Amendment Act, 1992
(Bill C-91). www.strategis.ic.gc.ca
33
Federal/Provincial/Territorial Task Force on Pharmaceutical Prices. (1999, April). Top Selling Nonpatented Single Source Drug Products, 1996: International Price Comparison. Conference of F/P/T
Deputy Ministers of Health, Charlottetown, P.E.I., June 17-18, 1999.
34
Canadian Institute for Health Information. (2001). National Health Expenditure Trends, 1975-2001.
Ottawa: CIHI.
35
Organization for Economic Cooperation and Development. (2001). OECD Health Data 2001.
Paris: OECD.
36
Anis AH, Guh D, Wang Xh. (2001). A dog’s breakfast: Prescription drug coverage varies widely
across Canada. Medical Care, 39(4), 312-314.
37
Grégoire JP, MacNeil P, Skilton K, Moisan J, Menon D, Jacobs P, McKenzie E, Ferguson B. (2001).
Inter-provincial variation in government drug formularies. Canadian Journal of Public Health, 92(4),
307-312.
38
Canadian Coordinating Office for Health Technology Assessment. (1997). Guidelines for
Economic Evaluation of Pharmaceuticals: Canada. 2nd ed. Ottawa: Canadian Coordinating Office
for Health Technology Assessment (CCOHTA).
39
Canadian Diabetes Association. (2001). Diabetes Report Card 2001.
www.diabetes.ca/news/reportcard/cda_report_card.pdf
40
Morgan S. (2001). Statistics and drug utilization: Are prescribing rates really that high?
(Commentary). Canadian Medical Association Journal, 165(11), 1507-1508.
41
Personal Communication. Sean Burnett, BC Pharmacare.
42
Health Canada, Therapeutic Products Program. (1999). Direct-to-Consumer Advertising of
Prescription Drugs: Discussion Document. Ottawa: Health Canada.
43
Mintzes B, Barer ML, Kazanjian A, Basset K, Evans RG, Morgan S. (2002). An Assessment of the
Health System Impacts of Direct-To-Consumer Advertising of Prescription Medicines (DTCA).
University of British Columbia, Vancouver: Centre for Health Services and Policy Research.
44
Premiers’ Health Conference. (2002, January).
www.gov.bc.ca/prem/popt/speech/jan_25_health_conference.htm
91
Part C: A Look Ahead
7. CONCLUSION
7. Conclusion
How should health services be financed, managed, and delivered? What
should be done to attract, recruit, and retain the best mix of health professionals
to meet a particular community’s needs? What should be done to improve
quality of care?
Canadians across the country are wrestling with these and many other important
questions about our health care system. Commissions have been struck. Politicians
debate the issues. Media stories abound. And Canadians are talking about what
our system is like today and where it should be in the years to come.
We are not alone. At the international level, the World Health Organization
(WHO) recently argued1 that the goals of a health system should be:
• Improving health status
• Reducing health inequalities
• Enhancing responsiveness to legitimate expectations
• Increasing efficiency
• Protecting individuals, families, and communities from financial loss
• Enhancing fairness in the financing and delivery of health care.
The WHO then tried to measure how well different countries were meeting
these goals. For its part, the Organization for Economic Cooperation and
Development recently announced a three-year review of health systems in each
of its 30 member countries. The aim of this exercise is to identify what countries
could or should be doing to more effectively and efficiently organize and deliver
health care services.
Before we can decide what should be, it helps to understand what is. That’s
what these annual reports, along with the companion How healthy are
Canadians? series are all about.
Health Care in Canada 2002 compiles the latest health system data and
trends—enriched by recent research findings—and highlights what we know and
don’t know about the country’s health care system. It charts many of the changes
in health care over the last decade. For example, the level and mix of spending
have fluctuated over this period. The largest share ($32.2 billion) of the record
$102.5 billion spent in 2001 still went to hospitals, but spending on drugs (now
$15.5 billion) has exceeded spending on physician services since 1997. At the
same time, overnight hospital stays are down, but day surgery use has grown. A
wide range of other important changes are occurring, from increases in
childhood obesity to new models for primary care and better information on
health outcomes.
HEALTH CARE IN CANADA 2002
But not everything is changing. For
example, most Canadians say that their
health is very good or excellent, although
differences remain within and across
communities. Regional differences in
factors that affect our health, in how health
services are organized and used, in health
outcomes, and in other areas also persist.
In addition, the challenges of promoting
health, preventing disease, and providing
high quality care endure, although the
yardsticks have shifted somewhat in the
decades since Medicare was introduced.
In several areas, we know more now
about what is changing, and what is not,
than in the past. This year’s report
showcases a variety of new and updated
information and research. For example, we
now know how patients fare 30 days after
being initially admitted to hospital for a
heart attack or stroke in regions across the
country. We also know how likely it is that
patients with different types of conditions
will be readmitted to hospital for further
care. Findings from the Canadian
Community Health Survey also offer new
insights into how health and the use of
health services vary from coast to coast.
We have come a long way, but there is
still a long journey ahead. Many questions
remain unanswered. And the world of
health care continues to evolve, even in the
two years since we published the first
Health Care in Canada report. A fuller
understanding depends on a broad range
of timely, reliable, systematic, and
comparable data and analysis that will fill
important information gaps.
In future reports, we hope to continue to
build on the base of knowledge that exists
today. We will also watch how Canada’s
health care system, the people who work
in it, and those who use it respond to the
recent health care reviews and other
winds of change.
96
Listening for Direction
In early 2001, CIHI and four other organizations
conducted a broad cross-Canada consultation on
priority health services and policy issues.2 Policymakers, managers, and clinical organizations
identified key areas where they had questions that
research could address over the next two to five
years. Eight primary themes came up often, in a
variety of forms, across many settings and
perspectives. They were:
• Health human resources
• Financing and public expectations
• Governance and accountability
• Driving and managing system change
• Improving quality
• Health care evaluation and technology
assessment
• Public advice-seeking in the era of e-health
• Improved access for ‘marginalized’ groups
In addition, the consultation process identified seven
secondary themes:
• Primary health care
• Globalization
• Regionalization
• Population health
• Continuum of care and delivery models
• Performance indicators, benchmarks,
and outcomes
• Evolving role of informal and voluntary care
This report touches on a number of these themes.
We hope to be able to explore several in more depth
in the future, as the state of information, analysis,
and research evolves.
Already, we are planning for 2003. We
welcome feedback from everyone—the
public, health professionals, and others—to
help us to continue to improve our ability
to meet your information needs. Please
contact us by filling out the feedback form
at the end of this report or by emailing us
at [email protected]
7. CONCLUSION
For More Information
World Health Organization. (1999). The World Health Report 1999: Making a Difference.
Geneva: World Health Organization.
2
Gagnon D, Ménard M. (2001). Listening for Direction: A National Consultation on Health Services
and Policy Issues. Ottawa: Advisory Committee on Health Services of the Conference of
Federal/Provincial/Territorial Deputy Ministers of Health, Canadian Coordinating Office for Health
Technology Assessment, Canadian Health Services Research Foundation, Canadian Institute for
Health Information, Institute of Health Services and Policy Research of the Canadian Institutes of
Health Research.
1
97
INDEX
Page numbers in italic indicate that the information
appears in a table, figure or sidebar.
Access to care 17-18
acupuncture 14
age
alternative therapy use 15
breast cancer 68
drug use 80, 81
health care resource use 35
health care spending 30-31
health status 13
satisfaction with health care 16
health care managers 28
Alberta
access to care 18
cancer screening 68
cancer survival rates 48
drug spending 85, 86,87
health care spending 6, 30-31
health ministers and deputies 28
health report 5, 6
heart attack and stroke 42-44, 46
hospitalizations 14
immunization 64-65, 66
organ donor rates 50
physicians 25, 33
regionalization 7, 8
satisfaction with health care 16
volume of care 54, 55
wait times 19
water safety 63
allergy medications 80
alternative therapies 14, 15, 21
antibiotics 81
antidepressants 81
Atlantic provinces, see also specific provinces
drug misuse 77
organ donor rates 50
breast cancer
screening for 9, 67-68
survival rates 48
wait times for surgery 19
British Columbia
cancer screening 67-68, 68
cancer survival rates 48, 48
drug spending 85, 86-88
health care spending 30-31
health ministers and deputies 28
health report 5
heart attack and stroke 42, 46
hospitalizations 14
immunization 66
medical students 26
organ donor rates 50
physicians 25
regionalization 7, 8
syphilis 67
volume of care 54, 55
wait times 19-20
water safety 62
bypass surgery 55
Canadian Cancer Society 9
Canadian Forces
emergency response 72
federal responsibility for health 13, 84
cancer
mortality 48, 49
screening for 9, 67-68
wait times for surgery 19
care providers, see also specific professions
changing roles 7
health care spending 32
information gaps 36
initiatives 36
numbers 23
reports about 23
roles 23
students 26-28
types 14, 23
cervical cancer 67-68
chickenpox 64
children
cancer 49
health promotion 69-70
immunization 64-65
obesity 70
Chinese medicine 15, 78
chiropractors
number of 23
visits to 14, 15
cholecystectomy 53
chronic conditions 15
Clair Commission, Quebec 5, 6
cocaine, in other drugs 77
colorectal cancer 19, 48
Commission on the Future of Health Care in Canada 1, 5
complementary therapies see alternative therapies
dental hygienists 23
dentists
and health care spending 31
number of 23
students 27
visits to 14
diabetes 9, 56, 66, 80, 81, 86, 87
digestive diseases 15
diphtheria 64, 65
disease prevention
cancer 67-68
immunization 63-66
role of public health 60
syphilis 67
water safety 60-63
drugs
abuse of 77
advertising 88
approval process 78, 79
health care spending 31-32, 84-88
information gaps 89
initiatives 89
legislation 77-78
newer vs. older 81-82
patents 82-83
post-marketing surveillance 79-80
prescription vs. over-the-counter 80
street drugs 71-72, 77, 78
usage patterns 80-81, 87-88
HEALTH CARE IN CANADA 2002
education
alternative therapy use 15
health care resource use 35
health status 13
dentists 27
health care managers 28
nurses 26
physicians 26
tuition in health care professions 27
electronic health records (EHRs) 34-36
emergency services
information gaps 21
public health response 72
Saskatchewan 5
wait times 19-20
exercise 15
eye specialists
number of 23
visits to 14
family caregivers 15
First Nations
federal responsibility for health 13, 84
water safety issues 61
Fyke Commission, Saskatchewan 5-6
gender
alternative therapy use 15
cancer survival rates 48
drug use 80
health care spending 30-31
heart attack or stroke 41-42
life expectancy 13
satisfaction with health care 16
trust in water safety 63
health care managers 28
health care workers 26
gynecologic cancer 19
Haemophilus influenzae type b (Hib) 64
head and neck cancer 19
health care
access 17-18
Canadians’ opinions of 16, 21
primary 8
health care managers
demographics 28
recruitment and retention 28
health care reports
across Canada 5-6
on care providers 23, 25
health care spending
drugs 84-88
growth 6, 29
information gaps 36
legislation 12
provincial/territorial differences 30-31
public/private mix 13, 29, 85
where the money goes 30, 32-34
health care system
federal responsibilities 13
history 12
international comparisons 95
satisfaction with 16, 21
health centres 8, 14
health information
CIHI 36
EHRs 34-36
initiatives 36
Internet 35
rapid expansion 34
health insurance
drug coverage 85-87
health care spending 31
introduced 12
pan-Canadian principles 12-13
health ministers and deputies 28, 56
health networks 8
health promotion
for children 69-70
HIV infection reduction 71-72
information gaps 36, 73
initiatives 73
policy document 60
role of public health 69
smoking reduction 15, 70-71
health services
alternative 6, 14, 15, 21
funding mix 13
initiatives 21
types used 14, 21
health status, determinants 12-13, 44-45, 59
heartburn medications 82
heart disease
hospitalizations 15
mortality 42-43
surgery wait times 20
treatment 41
heart medications 81
heart transplants 49, 51
hepatitis B 64
herbal medicine 15, 78
Hib (Haemophilus influenzae type b) 64
HIV infection 71-72
home care 32, 33, 34
homeopathy 14, 15
hospitalizations
acute care 14, 15
asthma 46-47
digestive diseases 15
heart attack and stroke 15, 41-43, 45-47
information gaps 56
pregnancy and childbirth 15
hospitals
admission wait times 20
health care spending 32
history 12
information gaps 21
legislation 12
satisfaction with 16
types 14
hysterectomy 15, 46, 53, 55
immigration, physicians 26
immunization
chickenpox 64
flu shots 66
for adults 64, 66
for children 64-65
information gaps 73
initiatives 73
smallpox 63-64
INDEX
income
and alternative therapy use 15
and drug use 80
and health care spending 32
and health status 13
influenza immunization 66
insulin 9, 49, 56, 77, 80, 87
international comparisons
drug approval times 79
drug costs 83, 84
drug use 81
EHRs 35
health care spending 29-30
health care systems 95
immunization 65
nurses’ job satisfaction 17
transplantation survival 52
wait times 19
water safety 60
Internet
as information resource 35
information gaps 36
islet cell transplantation 9, 49, 56
joint replacement
care volumes 53-54
registry 21
wait times 19
kidney transplants 49, 50, 52
Kirby Commission 1, 5
Labrador see Newfoundland and Labrador
life expectancy 13, 21, 29
liver transplants 49, 51, 52
low birth weight 69
lung cancer 48, 56, 71
lung transplants 49
mammography 9, 67-68, 69
Manitoba
cancer screening 68
cancer survival rates 48
drug spending 85, 86, 87
health care spending 30-31, 30
health ministers and deputies 28
home care 34
hospitalizations 14
immunization 64, 66
joint replacements 54
organ donor rates 50
physicians 25, 33
regionalization 7
wait times 19
marijuana 78
massage therapy 14, 15, 32
Mazankowski Report, Alberta 5, 6
measles 60, 64, 65
men
alternative therapy use 15
cancer survival rates 48
health care spending 31
health care workers 26, 28
heart attack or stroke 41-42
life expectancy 13
satisfaction with health care 16
trust in water safety 63
midwives 23
minerals, use of 15, 78
mortality
after transplantation 51, 52
and hospital volume 2, 52-53, 56
from cancer 9, 48, 4, 67-68
from heart disease 41,42-43
from stroke 2, 43, 56
information gaps 6, 56
mumps 64
naturopathy 14, 32
needle exchange programs 71-72
New Brunswick
cancer screening 68
cancer survival rates 48
drug spending 85, 86, 87
health care spending 30-31
health ministers and deputies 28
health report 5
hospitalizations 14
immunization 66
physicians 25
regionalization 7, 8
wait times 19, 20
Newfoundland and Labrador
cancer screening 68
cancer survival rates 48
drug spending 85, 86, 87
health care spending 30, 31
health ministers and deputies 28
hospitalizations 14
immunization 66
nursing students 26
physicians 25
regionalization 7
water safety 62, 63
North Battleford, Saskatchewan 59, 60
Northwest Territories
drug spending 85-87
health care spending 30-31
health ministers and deputies 28
health report 5
hospitalizations 14
immunization schedule 64, 66
physicians 25
regionalization 7
Nova Scotia
cancer screening 68
cancer survival rates 48
drug spending 85-87
health care spending 30-31
health ministers and deputies 28
heart attack and stroke 42, 44-46, 47
hospitalizations 14
immunization 64, 66
joint replacements 54
physicians 25
regionalization 7
wait times 19-20
Nunavut
drug spending 85
health care spending 30-31
health ministers and deputies 28
HEALTH CARE IN CANADA 2002
nurses
hospitalizations 14
immunization schedule 64
physicians 25
regionalization 7
job satisfaction 17
migration 25
number of 23, 24
provincial/territorial numbers 24
recruitment and retention 26
reports 23, 25
roles 7, 24
rural vs. urban 25
students 26-27
Ontario
cancer screening 68
cancer survival rates 48
day surgeries 15
drug spending 82, 83, 85, 86, 87
fee-for-service physicians 7
health care spending 12, 30-31
health ministers and deputies 28
health networks 8
heart attack and stroke 41-47
hospitalizations 14
immunization 64, 66
medical students 26-27, 28
organ donor rates 50
physicians 7, 17, 25
regionalization 7
satisfaction with health care 16, 20
transplantations 51, 52
wait times 19, 20, 21
water safety 60, 61, 62-63
optometrists 23
organ donation 49-50, 51, 56
orthodontists 14
outcomes of care
asthma 46-47
cancer 48, 49
heart attack 41-47
information gaps 56
initiatives 56
stroke 41, 43, 44-45
surgery 52-55
transplantation 49-52
painkillers 80-81
pancreas transplants 49, 50
pancreatic cancer 53, 55
pap smears 67, 68-69
penicillin 81
pertussis (whooping cough) 64
pharmacists 23, 35, 79, 82
physicians
alternative payment plans 32, 33
as health information resource 35
changing mix 17
fee-for-service 7,8, 26, 32, 33
health care spending 32
health promotion 69
number of 17, 23, 25-26
prescribing patterns 87, 88
recruitment and retention 25
roles 25
students 26-27
use of Internet 35, 36
view of EHRs 34, 35
visits to 14, 18, 21, 33
wait times 19, 21
workload 26
physiotherapists 23, 32
poliomyelitis 64
pregnancy and childbirth
drug use 79
hospitalizations 15
immunization 64
Prince Edward Island
cancer screening 68
drug spending 85, 86, 87
health care spending 30, 31
health ministers and deputies 28
hospitalizations 14
immunization 64, 66
nursing 24
nursing studies 26
physicians 25
regionalization 7, 8
prison inmates 13, 84
prostate cancer 48
proton pump inhibitors 82
provinces
cancer screening 68
cancer survival rates 48
drug spending 84-86, 87
health care spending 6, 30-32
health ministers and deputies 28
heart attack and stroke 42, 43, 44, 46-47
hospitalizations 14
immunization 64, 66
joint replacements 54
nurses 24-25
organ donor rates 50
physicians 25
regionalization of health care 7-8
transplantations 51
water safety 62-63
psychologists 2, 32
public health
disease prevention 60-68
emergencies 72
health promotion 8, 12, 36, 60, 69-72, 73
history 59
roles 59
Quebec
cancer screening 68
drug spending 85, 86, 87
health care managers 28
health care spending 30-31
health insurance 6
health ministers and deputies 28
health reports 5, 6
hospitalizations 14
immunization 66
joint replacements 54
nurses’ role 7
organ donor rates 50
INDEX
physicians 25
regionalization 7, 8, 55, 96
transplantations 51, 52
wait times 19
water safety 63
Red Cross 72
regionalization 5, 7-8
research
islet cell transplantation 9, 49, 56
stem cell 9
Royal and other commissions
Clair Commission, Quebec 5, 6
Future of Health Care (federal) 1, 5
Fyke Commission, Saskatchewan 5-6
Kirby Commission (federal) 1, 5
Mazankowski Report, Alberta 5, 6
Royal Canadian Mounted Police 13, 84
rubella 64
rural areas
nurses 25
physicians 7, 26, 27
Saskatchewan
cancer screening 68
cancer survival rates 48
drug spending 85, 86, 87
emergency response 5
fee-for-service physicians 8
health care spending 6, 30-31
health ministers and deputies 28
health report 5
heart attack and stroke 42, 44, 46
hospital insurance 12
hospitalizations 14
immunization 66
joint replacements 54
organ donor rates 50
physicians 25
regionalization 5, 7, 8
satisfaction with health care 16
wait times 21
water safety 60
seniors
drug coverage 86, 87
drug use 80, 81
flu shots 66
health care spending 31
satisfaction with health care 16
sex practices
HIV infection 71
syphilis infection 67
SIDS (sudden infant death syndrome) 69-70
sleeping pills 81
smallpox 12, 60, 63-64
smoking 67, 69, 73
quitting or reducing 15, 70-71
rates 70
spending see health care spending
stem cell research 9
stomach remedies 81
stroke 56, 71, 96
hospitalizations 15
mortality 43-45
treatment 41
sudden infant death syndrome (SIDS) 69-70
surgery
centralizing 55
day 15
effect of case volume 52-54
information gaps 56
transplantation 49-52
wait times 18, 19, 20
syphilis 60, 67
territories
drug spending 84-86
health care spending 30-32
health ministers and deputies 28
heart attack and stroke 42, 46-47
hospitalizations 14
immunization 64, 66
nurses 24
physicians 25
regionalization of health care 7-8
water safety 62
tetanus 64, 65
thalidomide 79
thoracic cancer 19
tranquilizers 81
transplantation
increasing 49
initiatives 56
mortality 51
organ supply 9, 49-50, 56
survival rates 50-52
xenotransplantation 51
urologic cancer 19
vaccination see immunization
varicella 64, 65
veterans 13, 84
vision care
number of optometrists 23
visits to specialists 14
vitamins, use of 15
wait times
defining 18
factors affecting 18-19
for admission 20
for donor organs 49-50
for surgery 19, 20
in emergency rooms 19-20
information gaps 21
initiatives 21
Walkerton 59, 60, 61, 62
water safety
boil-water advisories 62, 63
Canadians’ opinions 63
contaminants 62
disease risks 60
guidelines 61-62
information gaps 73
initiatives 73
weight
children 70
effect on health 69
initiatives 73
weight loss 15
HEALTH CARE IN CANADA 2002
Western Canada Waiting List Project 21
Western provinces, see also specific provinces
transplants 51, 52
Whipple procedure 53, 55
whooping cough (pertussis) 64
women
alternative therapy use 15
breast cancer 9, 19, 48, 67-68
cancer survival rates 48
cervical cancer 67-68
drug use 80
health care spending 31
health care workers 26, 28
heart attack or stroke 41
life expectancy 13
satisfaction with health care 16
trust in water safety 63
World Health Organization
breast cancer screening 9, 68
drug prescriptions 80
health care systems 95
immunization 63-64
xenotransplantation 51
Yukon
drug spending 85
health care spending 30-31
health ministers and deputies 28
hospitalizations 14
physicians 25
regionalization 7
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Highlights
A Year in the Life of Canada’s
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Care and Caring
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Public Health: On Guard Year
After Year
Medicating Illness: Drug Use and
Cost In Canada
Conclusion
Health Indicators 2002 (insert)
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HEALTH CARE IN CANADA 2002
5. How do you plan on using the information presented in this report?
Other Comments
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